Tobacco-Free Environments Overview The effects of secondhand smoke exposure on children are staggering. Pregnant women exposed to high levels of secondhand smoke are more likely to give birth to low birth weight babies than pregnant women who are not exposed to secondhand smoke1. Infants exposed to secondhand smoke have a higher risk of Sudden Infant Death Syndrome (SIDS)1. Children exposed to secondhand smoke have a greater risk of developing chronic respiratory illness, otitis media, and asthma1, and miss more days of school a year than children not exposed to secondhand smoke2. Taking into account these health risks, the 2006 Surgeon General Report titled The Health Consequences of Involuntary Exposure to Tobacco Smoke, announced that no safe level of exposure to secondhand smoke exists.1

AAP Recommendations Smoke-free environments are the best environments for children. In order to limit the exposure of children to secondhand smoke, the 2009 AAP Policy Statement, Tobacco Use: A Pediatric Disease, recommends the following:

Use of tobacco products in all indoor and outdoor public places should be prohibited.

Federal, state, and local governments should enact and enforce laws mandating the provision of smoke-free environments in all public places and require employers to provide smoke-free work environments for their employees.

Health care and educational facilities should be completely tobacco free, inside and outside, at all times. This includes all buildings, grounds, parking lots, satellite facilities, vehicles, and temporary venues.

Tobacco-dispensing machines and sale of tobacco products should be prohibited from schools, hospitals, affiliated clinics, and pharmacies. The only exception to this would be legitimate research centers that study tobacco use or cessation.

Foster families should provide smoke-free environments to children whenever possible but specifically in the home and in vehicles used to transport children. These spaces should remain smoke free even when children are not present to reduce the exposure via off-gassing

or thirdhand smoke.3

Pediatricians should counsel parents on the importance of tobacco-free homes, cars, schools, child care programs, playgrounds, and other venues.

Smoke-free Environments and Secondhand Smoke Clean Indoor Air A number of states have enacted laws to prohibit smoking in bars and restaurants4. While these laws signify progress in the goal to achieve smoke-free environments, there are still environments that may expose individuals to secondhand smoke. Advocates for smoke-free environments can urge state legislatures to adopt laws covering public places and environments such as:

rental dwellings outdoor areas (such as parks and beaches) vehicles correctional facilities health care facilities casinos universities, colleges, schools, and daycares other public places that permit smoking Smoking in the Workplace Public health advocates define comprehensive smoking legislation as laws that require all workplaces to be free from tobacco smoke5. However, some states deemed to have comprehensive smoking regulations provide exceptions for private workplaces, outdoor restaurant/bar seating areas, hotels, and other facilities such as casinos. Smoke-free workplace legislation is actually found to help businesses, and model policies are available for those looking to draft a policy6.

Smoking in Vehicles with Children Children are at risk of exposure to secondhand smoke when riding in cars with smokers. A 2006 study from researchers at the Harvard School of Public Health found that smoking in vehicles triggered harmful levels of secondhand smoke exposure within only five minutes7. The study also noted that carbon monoxide levels increased significantly as a result of smoking in vehicles7. It is important to note that while AAP policy supports reducing childrens exposure to secondhand

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in all environments, including vehicles, states should also consider unintended consequences (such as the risk of profiling drivers). Smoking in Multi-unit Housing A study measuring effects of secondhand smoke on children in multi-unit housing found that 54% of children who did not live with a smoker in their apartment still showed evidence of secondhand smoke exposure through measureable amounts of cotinine8. This effect may have been due to tobacco smoke seeping through walls or ventilation systems. The study concluded that restrictions on smoking in multi-unit housing may reduce childrens exposure to secondhand smoke8. Smoking on College Campuses Some states prohibit smoking on public college campuses, while others prohibit any tobacco use on campus property9. Though most colleges prohibit smoking in campus buildings, students attending schools without a campus-wide restriction may still be exposed to high concentrations of secondhand smoke while walking between campus buildings. For instance, some colleges merely restrict smoking to areas where ventilation is adequate or have designated smoking areas, meaning that students are still exposed to secondhand smoke if they are unable to avoid walking by areas where smoking is permitted. Smoking in Public Places More communities are moving towards making public spaces smoke free. This can include beaches, parks, transit waiting areas, recreation areas, and events like markets and fairs10. These types of laws can be tough to enforce, as most of these policies are self-enforced. Find out what areas near you are protected by tobacco- and smoke-free legislation by visiting the Americans for Nonsmokers Rights Web site at www.no-smoke.org. Advocacy Considerations Smoke-free environments are good for children and good for business The 2006 Surgeon General Report examined numerous economic impact studies and concluded that smoke-free workplace laws had no adverse impact on local hospitality industry1. Additionally, in 2010, an economic analysis of smoke-free laws concluded that they do not hurt (and may even improve) restaurant or bar businesses11.

Smoke-free laws are popular among the public According to the 2013 nationwide Social Climate Survey of Tobacco Control, more than 73% of those surveyed favor a law that would prohibit smoking in all indoor workplaces, including offices, restaurants, and bars. Many respondents felt that smoking should be eliminated from the following places: outdoor parks, 34%; beaches, 40%; inside of multi-unit housing, 59%; porches and balconies of multi-unit housing, 43%; outdoor seating areas of restaurants, 53%; outdoor areas of college campuses, 41%; sidewalks, 45%; twenty feet from a door, 70%. More than 88% of respondents felt that people should not be allowed to smoke in a car with a child present12. Demonstrate how easily smoke-free laws can be enforced Smoke-free laws tend to be self-enforcing and typically have enforcement mechanisms in place to ensure that environments remain tobacco free. Encourage states to implement laws that prohibit smoking in all school buildings and on campuses These laws should apply to both public and private colleges and universities. At least one study has shown tobacco use to be significantly lower among students living in smoke-free college housing compared with students living in housing where smoking is allowed, supporting the idea that such restrictions encourage prevention. Encourage owners of multi-unit apartment buildings and condominium developers to include nonsmoking clauses in leases and sales agreements There is no constitutional right to smoke. Leases and sales agreements should include terms addressing smoking in both common areas and in units. Because apartment owners and condominium developers often falsely believe the law prohibits them from restricting smoking in units and buildings, state laws should be amended to clarify the legality of nonsmoking clauses. Consider policy change at every level of government If implementing smoke-free laws at the state level is not possible, implementation of local smoke-free laws can serve as an example for state legislatures and increase awareness of and demand for smoke-free environments. States should either avoid preempting local smoke-free laws or lift existing preemptions that may prevent enactment of smoke-free ordinances.

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Seek pediatrician appointment to state tobacco advisory committees AAP state chapters provide an excellent opportunity to represent the voice of children and the profession of pediatrics on statewide tobacco advisory committees or task forces.

Tobacco addiction is a childrens health issue Almost 90% of adult smokers smoke their first cigarette prior to age 1813. Children, especially preschool children, are exposed to secondhand smoke more often than adults because of their close proximity to adults who smoke14. In the 2013 Youth Behavior Risk Survey, the Centers for Disease Control and Prevention estimated that approximately 5.6% of high school students were current smokers (smoked cigarettes on 20 of the previous 30 days)15.

AAP Resources AAP Julius B. Richmond Center of Excellence http://www.aap.org/richmondcenter/

AAP Policy Statement Tobacco Use: A Pediatric Disease http://www2.aap.org/richmondcenter/pdfs/2009PolicyStatement.pdf AAP Tobacco Prevention Policy Tool http://www2.aap.org/richmondcenter/TobaccoPreventionPolicyTool/index.html

Other Resources American Lung Association State Legislated Actions on Tobacco Issues (SLATI) http://www.lungusa2.org/slati

Campaign for Tobacco Free Kids Secondhand Smoke, Kids and Cars http://www.tobaccofreekids.org/research/factsheets/pdf/0334.pdf Campaign for Tobacco Free Kids Smoke-Free Laws Do Not Harm Business at Restaurants and Bars http://www.tobaccofreekids.org/research/factsheets/pdf/0144.pdf Campaign for Tobacco Free Kids U.S. State and Local Issues Smoke-Free Laws http://www.tobaccofreekids.org/what_we_do/state_local/smoke_free_laws/ Centers for Disease Control and Prevention Healthy Homes Manual: Smoke-Free Policies in Multiunit Housing http://www.cdc.gov/healthyhomes/Healthy_Homes_Manual_WEB.pdf Centers for Disease Control and Prevention Smoking and Tobacco Use: Fast Facts http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm Centers for Disease Control and Prevention Smoking and Tobacco Use: Youth and Tobacco Use http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm Centers for Disease Control and Prevention Tobacco Control State Highlights 2012 http://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2012/index.htm Centers for Disease Control and Prevention Ventilation Does Not Effectively Protect Nonsmokers from Secondhand Smoke http://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/protection/ventilation/index.htm Institute of Medicine Ending the Tobacco Problem: A Blueprint for the Nation http://www2.aap.org/richmondcenter/pdfs/IOMReport_BluepintforNation.pdf National Association of Attorneys General (NAAG) Tobacco http://www.naag.org/tobacco.php

WHAT YOU CAN DO TO ACHIEVE SMOKE-FREE ENVIRONMENTS IN YOUR STATE

Share these advocacy considerations and your concerns about tobacco-free environments with your states AAP chapter. Communicating with your states AAP chapter is an excellent way to voice your opinion, build coalitions and relationships with pediatricians and other physicians, increase statewide awareness of the issue, and ultimately motivate state lawmakers to strive for smoke-free environments during legislative sessions.

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Tobacco-Free College Campus Initiative http://tobaccofreecampus.org/ Citations 1) U.S. Department of Health and Human Services: The Health Consequences of Involuntary Exposure to Tobacco Smoke: a Report of the Surgeon General (2006) http://www.ncbi.nlm.nih.gov/books/NBK44324/

2) Levy D., Winickoff J., Rigotti N. School Absenteeism Among Children Living With Smokers. Pediatrics. 2011; 128(4): 650 -656. 3) Thirdhand smoke is the smoke residue left in an environment after smoking has ceased. Some components of thirdhand smoke can remain for weeks and provide a lasting source of exposure. For more information, see the AAP Richmond Center Web site: http://www2.aap.org/ richmondcenter/DangerFromThirdhandSmoke.html 4) Americans for Nonsmokers Rights: Smokefree Lists, Maps, and Data. Available at http://www.no-smoke.org/ goingsmokefree.php?id=519. Accessed February 20, 2015.

5) Americans for Nonsmokers Rights: 100% Smokefree Definitions. Available at http://www.no-smoke.org/ document.php?id=758. Accessed February 20, 2015.

6) Americans for Nonsmokers Rights: In Your Workplace. Available at http://www.no-smoke.org/goingsmokefree .php?id=103. Accessed February 20, 2015. 7) Rees V., Connolly G. Measuring Air Quality to Protect Children from Secondhand Smoke in Cars. Am J Prev Med. 2006; 31(5): 363-368. 8) Wilson K., Klein J., Blumkin A., Gottlieb M., Winickoff J. Tobacco-Smoke Exposure in Children Who Live in Multiunit Housing. Pediatrics. 2011; 127(1): 85-92. 9) Americans for Nonsmokers Rights: U.S. Colleges and Universities with Smokefree and Tobacco-Free Policies. Available at http://www.no-smoke.org/pdf/ smokefreecollegesuniversities.pdf. Accessed October 1, 2013. 10) Americans for Nonsmokers Rights: Smokefree Outdoor Air. Available at http://www.no-smoke.org/learnmore. php?id=669. Accessed February 20, 2015. 11) Campaign for Tobacco-Free Kids: Smoke-free Laws do not Harm Business at Restaurants and Bars. Available at http://www.tobaccofreekids.org/research/factsheets/pdf/0144.pdf. Accessed February 20, 2015.

12) 2013 National Social Climate Survey of Tobacco Control (unpublished) 13) US Department of Health and Human Services, Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General (2012). http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html. 14) Best D., Committee on Environmental Health, Committee on Native American Child Health, Committee on Adolescence. (2009). Technical Report: Secondhand and Prenatal Tobacco Smoke Exposure. Pediatrics; 124(5): 1017-1044. 15) Kann L., et al. Youth Risk Behavior Surveillance United States, 2013. Morbidity and Mortality Weekly Report. 2014; 63(4): 1-168.

CONNECTING WITH YOUR STATE AAP CHAPTER IS EASY This brief provides an introduction to state government issues and additional background information that can be used when communicating about secondhand smoke issues and smoke-free environments. To locate your states AAP chapter, please visit the AAP Chapter Contacts Listing page on the AAP Web site: http://www.aap.org/member/chapters/chaplist.cfm

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Tobacco-Free Environments