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Secondhand Smoke

Volume 5, Number 5 - June/July, 2001

Editors: Carol A. Rice, Ph.D., RN, Professor and Extension Health Specialist, and Janet M. Pollard, MPH, Extension Associate-Health

Inside HealthHints....

• Secondhand Smoke
• What is Secondhand Smoke?
• How Does Secondhand Smoke Affect Health?
• How Can I Reduce Exposure to Secondhand Smoke?
• How Do I Ask Others Not to Smoke?
• Saying Goodbye to Smoking: Some Successful Cessation Methods
• The Cost of Secondhand Smoke
• The Law
• Program Ideas
• Resources
• Websites with Reliable Information
• References

Secondhand Smoke

Tobacco use is the single largest cause of preventable death and disease in Texas.... Each year tobacco kills more Texans than AIDS, crack, heroin, cocaine, car accidents, suicides, fire, and murder -- combined. Tobacco use is associated with increased mortality from heart disease, stroke, and cancer (including cancer of the lung, lip, oral cavity, pharynx, esophagus, pancreas, larynx, cervix uteri, urinary bladder, and kidney), chronic lung disease, low birth weight, respiratory distress syndrome, and sudden infant death syndrome (SIDS) (Texas Department of Health, 1997b).

This issue of HealthHints will focus on this very serious and costly problem -- secondhand smoke -- what it is, how it affects health, and how to reduce exposure to it. Smokers must understand that if they cannot stop smoking, they must make every effort to keep from exposing others, especially children, to their tobacco smoke.

What is Secondhand Smoke?

Secondhand smoke (also known as environmental tobacco smoke [ETS], or passive or involuntary smoking) is the mixture of particles from the burning end of a cigarette, cigar, or pipe and the smoke breathed out by the smoker (National Safety Council, 2000). These two types of smoke are known as:

• Mainstream smoke -- the smoke exhaled from the lungs of the smoker; and
• Sidestream smoke -- the smoke that curls up from the burning end of a cigarette, cigar, or pipe (Environmental Protection Agency, 2001b; Waite, 1994).

Sidestream smoke is actually more dangerous than mainstream smoke. Tobacco actually burns cleaner at the higher temperatures generated when a smoker inhales. Allowing a cigarette to smolder in the ashtray between puffs is very hazardous to those who must be around the smoker such as young children. While filters screen out some of the toxins for the smoker when inhaling, sidestream smoke, burning at lower temperatures and with no filter emits:

• 5 times as much carbon monoxide (a dangerous gas that robs blood of its ability to carry oxygen),
• 3 times as much benzopyrene (a substance that can cause cancer), and
• 50 times as much ammonia (a potent eye and respiratory tract irritant) as mainstream smoke (Waite, 1994).

More than 4,000 chemical compounds have been identified in secondhand smoke. Of these, 200 are poisons (toxins) and at least 43 cause cancer (American Lung Association, 2000a; Centers for Disease Control, 2000a; Texas Department of Health, 1997a). Thus, every time you inhale smoke-filled air you draw chemicals such as cadmium (a cancer-causing metallic element), ammonia (used in toilet cleaners), benzene (used in manufacture of DDT), acetone (a powerful solvent), formaldehyde (a component of embalming fluid), and carbon monoxide (a dangerous gas) into your body (Texas Department of Health, 1997a).

How Does Secondhand Smoke Affect Health?

Secondhand smoke has been classified as a Group A carcinogen under the U.S. Environmental Protection Agency's (EPA) carcinogen assessment guidelines. This classification is reserved for those compounds or mixtures shown to cause cancer in humans, based on human populations (Environmental Protection Agency, 1993a).

A human carcinogen is a cancer-causing substance for which a cause-effect relationship has been established in humans (Perera, 1997).

Based on an extensive review of the available scientific evidence, the EPA has concluded that widespread exposure to environmental tobacco smoke [secondhand smoke] in the U.S. presents a serious and substantial public health risk (Environmental Protection Agency, 1993a). Some of the health risks related to secondhand smoke include:

• Lung cancer
• Heart disease and stroke
• Respiratory illness and irritation
• Impaired lung function
• Ear problems
• Asthma
• Decreased endurance
• Sudden infant death syndrome (SIDS)
• Low birth weight infants.

Lung Cancer

According to the EPA, secondhand smoke is a human lung carcinogen, responsible for approximately 3,000 lung cancer deaths annually in U.S. nonsmokers (Environmental Protection Agency,1993a). The National Academy of Sciences, U.S. Surgeon General, and a wide array of other professional medical associations have also concluded that secondhand smoke causes lung cancer in nonsmokers (Mayo Clinic, 2000).

Heart Disease and Stroke

Certain elements of secondhand smoke can cause blood to clot and arterial linings to be damaged. Additionally, carbon monoxide limits the amount of oxygen that reaches the heart muscle. These factors combined can result in heart attack or stroke (Bunt, 1997).

A 1997 study of 32,000 nurses found that women regularly exposed to secondhand smoke were at twice the risk for heart attack compared to those not regularly exposed to secondhand smoke. This study controlled for other factors, such as high blood pressure and high cholesterol (Mayo Clinic, 2000).

Respiratory Illness and Irritation

Secondhand smoke is especially dangerous to young children. Secondhand smoke impairs the respiratory health of hundreds of thousands of children each year (American Cancer Society, Texas Cancer Council Texas Oncology Education Programs, 1998). Exposure to secondhand smoke increases the risk of lower respiratory tract infections such as bronchitis and pneumonia. EPA estimates between 150,000 and 300,000 of these cases annually in infants and young children are attributable to secondhand smoke. Of these cases, between 7,500 and 15,000 will result in hospitalization (Environmental Protection Agency, 1993a).

Additionally, due to irritation of the lungs and respiratory tract, secondhand smoke can produce coughing, wheezing, phlegm, and chest discomfort in nonsmoking children and adults (American Lung Association,1996; Environmental Protection Agency,1993b; Waite, 1994).

Among the most common and firmly established adverse health effects are also irritation of the eyes, nose, and upper respiratory tract (American Council on Science and Health, 1998). This irritation may result in reddened, itchy, watery eyes and a burning sensation of the eyes, nose, and throat (Centers for Disease Control, 2000a).

Secondhand smoke may also result in longer recovery from colds and other illnesses (Parrott et. al., 1999).

According to the Centers for Disease Control (CDC, 1997), children living with smokers spend more days on activity restriction and also confined to bed. Further, they also miss more days of school each year than children living in smoke-free homes.

Impaired Lung Function

Because a child's body is still developing, exposure to the poisons in secondhand smoke can hinder lung growth and result in decreased lung function (American Lung Association, 2000c; Centers for Disease Control, 2000b). Children of parents who smoke have a slower rate of growth in lung function as the lung matures -- the effects can last a lifetime (American Lung Association, 2000b; Centers for Disease Control, 2000b). It has also been suggested that these children may be susceptible to the development of lung disease in adult life (American Lung Association, 2000b).

Ear Problems

Children regularly exposed to secondhand smoke also experience more ear infections and hearing problems (Parrott et. al., 1999). Secondhand smoke exposure causes buildup of fluid in the middle ear, resulting in 700,000 to 1.6 million physician office visits. Middle ear infections are the most common cause of childhood operations and of childhood hearing loss (American Lung Association, 2000c).

Asthma

Secondhand smoke can trigger episodes of asthma and/or aggravate symptoms, making them more severe, in children who already have asthma. It is estimated that 200,000 to 1 million asthmatic children have their condition worsened by exposure to secondhand smoke (Environmental Protection Agency, 1993a).

Secondhand smoke is also a risk factor for new cases of asthma in children who have not previously exhibited asthma symptoms -- increasing the likelihood of developing asthma (Parrott et. al., 1999; Environmental Protection Agency, 2001). Each year mothers who smoke at least 10 cigarettes a day can cause 8,000 to 26,000 new cases of asthma among their children (Centers for Disease Control, Office on Smoking and Health, 2000b; Texas Department of Health, 1997a). (For more information on asthma, see the May 1999 issue of HealthHints.)

Decreased Endurance

Exposure to secondhand smoke can decrease your ability to exercise. This is most likely due to the exposure to carbon monoxide in the smoke, which replaces oxygen in the bloodstream (Waite, 1994).

Sudden Infant Death Syndrome (SIDS)

Maternal smoking during pregnancy is associated with an increased incidence of Sudden Infant Death Syndrome (Environmental Protection Agency, 2000a)

Several recent studies have linked secondhand smoke exposure with sudden infant death syndrome (SIDS). A California EPA study estimated 1,900 to 2,700 SIDS deaths annually associated with secondhand smoke (American Lung Association, 2000c). A recent study also found that infants are three times more likely to die from SIDS if their mothers smoke during and after pregnancy; and twice as likely if their mothers stop during pregnancy and resume smoking following birth (Centers for Disease Control, 2000a; Mayo Clinic, 2000). A recent study in England of over 350,000 live births found that SIDS could be reduced by as much as 2/3 if parents did not smoke. Additionally, for every hour an infant spends each day in a room where people smoke, the risk of SIDS doubles compared to those in smoke-free environments. An infant exposed to four hours of indoor secondhand smoke is four times more likely to die from SIDS as a nonexposed child (Texas Department of Health, 1997a).

Low Birthweight Infants

Babies born to smoking mothers also have a lower average birthweight. Low birthweight babies are at higher risk for sickness and death (Bunt, 1997). About 2,800 deaths each year are linked to low birthweights caused by smoking while pregnant (Texas Department of Health, 1997a).

Note: If you think about smoking during pregnancy -- think again. The smoke:

• smoke crosses the placenta,
• enters the amniotic fluid, an
• significantly decreases oxygen to the fetus (Giddings, et. al., 1994).

How Can I Reduce Exposure to Secondhand Smoke?

It is not easy to avoid secondhand smoke because about one in four people smoke (American Lung Association, 2001a).

It is best to be in a smoke-free environment, but this may not always be possible, and you may have to make some compromises. Here are some tips for creating a smoke-free environment and reducing your exposure and your childrens' exposure to secondhand smoke.

In the Home

• Do not smoke in your home.
• Ask visitors not to smoke in your home.
• Make sure people you hire to work in your home do not smoke, particularly babysitters and others that care for your children.
• Use no-smoking signs, buttons, and stickers at home, as well as at work and in your car.

At Work and School

• Check your child's daycare site or school to be sure they are smoke-free. Help other parents and childcare providers to understand the serious health risks associated with secondhand smoke. Work with parent/teacher associations, school board members, community leaders and other concerned citizens to make your children's environments smoke free.
• Seek a worksite that has a smoke-free policy in place. (If your worksite does not have a smoking policy that protects nonsmokers from secondhand smoke, try to join with co-workers to get one implemented. See if your worksite will ban smoking indoors, or at least designate a separately ventilated smoking room that nonsmokers do not have to enter as part of their work responsibilities.)

At Businesses Where You're the Consumer

• Patronize nonsmoking businesses, and tell the owners or managers how important this is to you.
• Ask to be seated in nonsmoking sections of restaurants and theaters. Ask to be moved if you are seated near smokers.
• If you choose not to patronize businesses that allow smoking, let the owners or managers know.

In Transit

• Make your car a smoke-free space.
• If you are riding in another person's car, ask them not to smoke.
• If someone is smoking in a vehicle you ride in, keep windows open.

In the Home with a Smoker

• Ask the smoker to smoke outside.
• Set up one smoking room. Choose a place with windows that can be opened and a fan, preferably an exhaust fan that takes the smoke outside; keep the door to the room closed. Keep in mind: Ventilation will reduce, but not eliminate exposure. Because smoking produces such large amounts of pollutants, natural or mechanical ventilation techniques do not remove them from the air in your home as quickly as they build up (Consumer Product Safety Commission and Environmental Protection Agency, 2001).
  Note: For more on air cleaning see "Air Cleaning: A Strategy for Reducing Pollutants in Indoor Air?" [http://fcs.tamu.edu/housing/iaq/aircleaners.htm] by Janie Harris, Housing and Environment Specialist.
• Keep windows open and air out the home frequently.
• Talk to the smoker about quitting, and help him/her to do so by providing ample support. (For more information, see sections in this newsletter on asking others not to smoke and smoking cessation ideas).
  Note: Moving to another room, opening windows, and ventilating will reduce exposure slightly, but not completely. The only complete protection for you and your children is not to smoke in the home or around the nonsmoker.

At Home with Guests Who Smoke

• Ask guests who smoke to do so outside; provide ashtrays on the porch or deck.
• Remove ashtrays from the home.

(Adapted from American Lung Association, 2000b; National Safety Council, 2000; Quackenbush, 1998; Environmental Protection Agency, 2000b; Environmental Protection Agency, 1993b.)

How Do I Ask Others Not to Smoke?

At first it can be awkward asking others, whether guests or family members, not to smoke around you and your children. Smokers may feel defensive about smoking, so it is critical to be polite. Here are some ideas that may help to reduce the tension, while helping others to become aware of the associated risks:

• If the smoker is a relative or close friend, let them know you care about them. Tell them you worry about how tobacco might harm them.
• If the smoker is your spouse, tell them the facts about secondhand smoke and that you're concerned about your children's health.
• If the smoker wants to quit, be sympathetic, supportive and understanding. Remember, tobacco is addictive, and it is not easy to give up. If the smoker is open to ideas, talk about ways to quit and what the smoker thinks might work best for him/her (see the section on smoking cessation in this issue of HealthHints).
• Put up a no smoking sign at your front door and do not have ashtrays inside the home. Have mints or gum available in a dish on the table for your guests. Simply and politely tell guests that you do not allow smoking in the home due to the associated health risks. If they want to know more, you can share the facts with them.
• If a visitor or family member must smoke, ask them to do so outside.
• If a family member insists on smoking inside, discuss having one room where smoking is permitted and ventilation is available in the form of windows and an exhaust fan.
• Tell babysitters that it is your policy not to allow smoking in your home or around your children.
• If someone smokes in public, you might politely "I was wondering if you would mind not smoking? The smoke tends to bother me."
• If someone is smoking in a nonsmoking area, you might approach them by saying "You might not realize it, but this is a nonsmoking area, smoking is not allowed past this point" -- you can them point out the smoking area, if necessary.

Most importantly, keep your tone and attitude positive and polite. Most people will respond more positively if they don't feel they are being attacked or judged (Centers for Disease Control, 2000b; National Cancer Institute, 2001; Waite, 1994).

Saying Goodbye to Smoking: Some Successful Cessation Methods

If you or someone in your family is a smoker, or you know someone who is a smoker who is ready to quit, here are some suggestions to help break the smoking habit.

Some successful cessation methods include:

Quitting in Steps

• Make the decision to quit.
• Set a quit date.
• Decide on a plan such as telling friends, setting up a support system, and avoiding high risk situations.
• Deal with the physical withdrawal symptoms with nicotine cessation aids.
• Deal with the psychological symptoms by engaging in activities where smoking is impossible such as exercising.
• Learn relaxation techniques, and schedule rewards for making it through another day, week, etc. without tobacco.
• Plan for maintenance by consciously reviewing your reasons for quitting and avoiding "having just one."

Quitting Cold Turkey

This method involves picking a "quit date" and marking it on the calendar. When the date arrives, the smoker gives up smoking completely.

Switching Brands

This method involves the smoker switching to a brand or type of cigarette that they dislike. They don't want to smoke as much because they don't really like what they are smoking, and they can gradually taper off and quit.

Nicotine Fading

This method involves gradually weaning the smoker away from nicotine by reducing the number of cigarettes they smoke each day.

Cessation Aids

Things like the nicotine patch, inhalers, nicotine gum, and prescription medications often increase the smoker's chances of quitting for good.

It is important to remember that nicotine is a drug and nicotine addiction is similar to cocaine or heroin addiction. When a smoker inhales the smoke from a cigarette, the nicotine in that cigarette causes changes in the smoker's brain, heart, lungs, and blood. People who have never smoked often think it should be easy to quit smoking, but you must understand that a smoker's body is dependent on the drug nicotine and the withdrawal their body goes through when the drug is removed is very real and very difficult to deal with (American Cancer Society, 2001b).

Texans wanting to stop smoking now have a toll free quitline to call for personalized assistance if they want. Call 1-877-YES-QUIT.

The Cost of Secondhand Smoke

In addition to the costs to our health, secondhand smoke also affects our pocket books. We all share the monetary costs that come with smoking and exposure to secondhand smoke, including:

• higher medical bills
• higher insurance premiums
• absenteeism and lower workplace productivity (American Cancer Society, 2001a; Chaning L. Bete,1993).

In the U.S.

• Annual public and private health care expenditures directly related to tobacco use = $89 billion
• Annual state and federal tax burden caused by tobacco-related health costs = $45 billion
• Federal government Medicaid payments each year directly related to tobacco use = $20.5 billion
• Annual additional expenditures for health and development problems caused by mothers smoking or being exposed to secondhand smoke during pregnancy = $1.4-$4.0 billion (Campaign for Tobacco Free Kids, 2000).

In Texas

• Annual health care expenditures directly related to tobacco use = $4.8 billion
• Residents' state and federal tax burden caused by tobacco-related health costs = $2.1 billion
• Texas government Medicaid payments directly related to tobacco use = $650 million
• Annual additional expenditures in Texas for babies' health problems caused by mothers smoking or being exposed to secondhand smoke during pregnancy = $89-$255 million (Campaign for Tobacco Free Kids, 2000).

The Law

Laws are made to protect us. When we know the law, we can insist that those in charge enforce it (National Cancer Institute, 2001); and we can seek ways to better our communities and policies where the law does not protect us. For a look at the law as it pertains to smoking and secondhand smoke nationwide see the fact sheet from the American Cancer Society entitled "Smoking Legislated Actions on Tobacco Issues".

Additionally, during the Clinton Administration, national legislation was passed into law restricting smoking in nearly all public places where federal assistance is provided for children (Environmental Protection Agency, 1994).

Here's a look at some of the legislation in Texas:

Senate Bill 1 (during the 1995 legislative session) prohibits smoking or using tobacco or possessing tobacco products on school property, or at a school-sanctioned function on or off school property (Texas Department of Health,1995).

Senate Bill 55 reduces children's access to tobacco by continuing penalties for store clerks who sell to minors, requiring retailer to verify age of purchasers younger than 27 years with photo identification, requiring signs posted that express that it is illegal to sell to minors and illegal for minors to buy tobacco, restricting vending machine and self-service sales as well as giveaways and coupons to minors, requires a retail permit fee of $125, subjects retailers to monetary penalties, and penalizes minors for purchase, prohibits advertising within 1,000 feet of a church or school (Texas Department of Health, 2001).

Additionally, several Texas cities have implemented, or are currently working on passing, clean air ordinances prohibiting smoking in restaurants and other public places. For a list of the cities and their specific ordinances see the insert in this issue of HealthHints entitled Indoor Clean Air Ordinances: Summary of Restaurant Smoking Regulations in Texas from the American Cancer Society.

Program Ideas

• Train volunteer educators to provide short programs to parent groups required to attend educational programs. Such groups include HeadStart, public housing, WIC, and others. See insert describing a short program, Put It Outside, Raising Healthy Children (http://fcs.tamu.edu/health/child_health/put_it_outside/put_it_outside.htm), done by Luwana Rider, Rural Health Specialist, in District 5.
• Train volunteer educators to provide short program to day care providers using the Training Module for Child Care Providers [http://www.epa.gov/iaq/ets/]. Agents could also provide this training at Child Care Providers conferences. This site also contains excellent, downloadable fact sheets and brochures.
• Include indoor air quality awareness activities as part of back to school activities like health fairs. See the Health Fair Planning Guide [http://fcs.tamu.edu/health/health_fair_planning_guide/index.htm] containing other hands-on health fair ideas.

Resources

Extension

Exhibits (Spanish and English)

Available at: District Extension Offices (Amarillo, Lubbock, Vernon, Dallas, Overton, Fort Stockton, San Angelo, Stephenville, Bryan, Uvalde, Corpus Christi, Weslaco) and Urban County Extension Offices (Harris, El Paso, Travis, Dallas, Tarrant, Bexar) except where noted.

• Smoking and Youth (Spanish and English, 1995)
• Second Hand Smoke. (X-1101, 1996, Educational Resource Library.) Model in plexiglass. This model collects the tars in secondhand smoke from a cigarette smoked in an enclosed chamber. The residue collected on a filter measurably demonstrates how much cancerous smoke a nonsmoker's lungs absorb from some else's cigarette.

Teaching Resources

Available at District Extension Offices and Educational Resource Center

• Smoking Effects and Hazards Display and overheads with carrying case (1996). This display shows why tobacco is America's #1 health problem. It helps viewers understand the initial and long-term effects of nicotine and smoke by-products on the human body. Dispels myths about smoking while showing how to quit, step by step, and how to avoid getting started in the first place.
• Death of a Lung (1996). The first model in this display shows, regular contours and healthy color of the normal, nonsmoker's lung tissue. The second model depicts the soft, irregular shape and blackened color of tissue from an emphysematous lung, with collapsing air sacs within the lung wall like the ones that will eventually smother the smoker. In the third model, cancer of the lung appears as a large, whitish-gray mass.
• Smoky Sam Secondhand Smoke Demo (1996). This model collects the tars in secondhand smoke from a cigarette smoked in an enclosed chamber. The residue collected on a filter measurably demonstrates how much cancerous smoke a nonsmoker's lungs absorb from someone else's cigarette.
• Smoky Room Secondhand Smoke Demonstrator. This model collects the secondhand smoke from a cigarette smoked in an enclosed chamber. The smoke collected in the chamber measurably demonstrates how much cancerous smoke a nonsmoker is exposed to from someone else's cigarette.

The following three educational resources are available from Family Development and Resource Management, phone (979) 845-3850.

• Environmental Tobacco Smoke Program (TDH). Blueprint on how to plan an ETS program with school-aged children in collaboration with the local health department, etc. Includes written materials, supplies, prizes, t-shirts, and pre/post-tests. Available in the fall on a first-come-first serve basis.
• Indoor Air Quality Games from the Indoor-Air. Contains a step-by-step guide on how to plan an Indoor Air Quality Awareness Day. Ask for information available on secondhand smoke, asthma, and allergies as well.
• Article on SIDS, by Dr. Steve Green and Dr. Linda Jouridine. Contains information on secondhand smoke, for inclusion in child-care worker training, etc.

The following resource was provided to those who participated in the Indoor Air Quality Training. Others may request one copy per county from Janie Harris, Extension Housing and Environment Specialist:

• Let's Take it Outside Flipchart (KSU Extension). Explains the dangers of secondhand smoke, particularly to children. Suggests ways for reducing exposure.

Videos

• Poisoning Our Children: The Perils of Second-Hand Smoke (VHS 2512, Educational Resource Library).
  This video reveals the health risks of secondhand smoke on children. It stresses the importance of not smoking around children, who are a greater risk because the possibility of damage to their developing organs. Animated graphics show how smoke harms the body: runny nose, postnasal drip, cough, wheezing, asthma, pneumonia, sinusitis, ear infections, colds and sore throats, bronchitis, and reduced lung infection.

Other Organizations

The following 3 resource packets are available free of charge, and come with pamphlets, fact sheets, and other relevant literature from the Texas Department of Health. Contact Paula Traffas, Public Health Technician, at (512)458-7402 or e-mail her at paula.traffas@tdh.state.tx.us.

• Community Environmental Tobacco Smoke Policy Development Packet
• Environmental Tobacco Smoke Packet
• Senate Bill 55/Texas Tobacco Law Packet

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References

• American Cancer Society (2001a). Smoking effects on kids [on-line]. Available:
  http://www2.cancer.org/eprise/main/docroot/
  NWS/content/NWS_1_1x_Smoking_Effects_on_Kids.
• American Cancer Society (2001b). Quitting smoking [on-line]. Available:
  http://www.cancer.org/tobacco/quitting.html.
• American Cancer Society, Texas Cancer Council, and Texas Department of Health (1997). Stop Tobacco's Toll on Texas [pamphlet]. Available: Texas Department of Health, 1-800-345-8647.
• American Cancer Society, Texas Cancer Council, and Texas Oncology Education Programs (1998). Tobacco Facts for the Clinician [booklet]. Funded by the Texas Cancer Council and American Cancer Society, Texas Division, Inc.
• American Council on Science and Health (1998). Environmental tobacco smoke: Health risk or hoax? Executive summary [on-line]. Available: http://www.acsh.org/publications/booklets/ets.html.
• American Lung Association (2000a). ALA Fact Sheet: Secondhand smoke [on-line]. Available: http://www.lungusa.org/tobacco/secondhand_factsheet99.html.
• American Lung Association (1996). Protecting kids from secondhand smoke at home may reduce breathing problems from colds [on-line]. Available: http://www.lungusa.org/press/medical/two.html.
• American Lung Association (2000b). Secondhand smoke [on-line]. Available: http://www.lungusa.org/air/air00_second.html.
• American Lung Association (2000c). Secondhand smoke and children [on-line]. Available: http://www.lungusa.org/tobacco/secondkids_factsheet.html.
• American Lung Association (2001a). Secondhand smoke and your family [on-line]. Available: http://www.lungusa.org/tobacco/smosecondha.html.
• American Lung Association (2001b). When you smoke your family smokes [on-line]. Available: http://www.lungusa.org/tobacco/fda.html.
• Bunt, A. (1997). The Dangers of Secondhand Smoke [booklet]. Available: Health Edco, http://www.healthedco.com/.
• Campaign for Tobacco-Free Kids (2000). Toll of Tobacco in the United States [on-line]. Available: http://tobaccofreekids.org/reports/settlements/.
• Centers for Disease Control and Prevention and Department of Health and Human Services - USA (2000a). Facts about secondhand smoke. Available from the Office of Tobacco Prevention and Control, Texas Department of Health, 1-800-345-8647.
• Centers for Disease Control and Prevention (2000b). Secondhand smoke in your home [on-line]. Available: http://www.cdc.gov/tobacco/research_data/environmental/etsfact3.htm.
• Centers for Disease Control and Prevention (1997). Smoking prevalence and exposure to tobacco smoke among children [on-line]. Available: http://www.cdc.gov/od/oc/media/fact/smoketsc.htm.
• Channing L. Bete (1993). What everyone should know about secondhand smoke [booklet]. Available: Channing L. Bete, 1-800-628-7733.
• Consumer Product Safety Commission and Environmental Protection Agency (2001). The Inside Story: A Guide to Indoor Air Quality [on-line]. Available: http://www.cpsc.gov/cpscpub/pubs/450.html.
• Environmental Protection Agency (2000a). Air they breathe [on-line]. Available: http://www.epa.gov/children.htm.
• Environmental Protection Agency (1993a). Respiratory health effects of passive smoking [on-line]. Available: http://www.epa.gov/iaq/pubs/etsfs.html.
• Environmental Protection Agency (2001a). Secondhand smoke [on-line]. Available: http://www.epa.gov/iaq/asthma/triggers/shs.html.
• Environmental Protection Agency (2001b). Secondhand smoke: Also known as environmental tobacco smoke [on-line]. Available: http://www.epa.gov/iaq/ets/.
• Environmental Protection Agency (1994). Setting the record straight: Secondhand smoke is a preventable health risk [on-line]. Available: http://www.epa.gov/iaq/pubs/strsfs.html.
• Environmental Protection Agency (2000b). Take the smoke-free homes pledge [on-line]. Available: http://www.epa.gov/iaq/ets/smokefree.html.
• Environmental Protection Agency (1993b). What you can do about secondhand smoke as parents, decision-makers, and building occupants [on-line]. Available: http://www.epa.gov/iaq/pubs/etsbro.html.
• Giddings, SS, Morgan, W., Perry, C, Isabel-Jones, J, Bricker, JT (1998). Active and passive tobacco exposure: A serious pediatric health problem [on-line]. Available: http://www.americanheart.org/Scientific/statements/1994/119401.html.
• Hayslett, JA, and Huang, PP (2000). Impact of clean indoor air ordinances on restaurant revenues in four Texas cities. Bureau of Disease, Injury and Tobacco Prevention, Texas Department of Health.
• Mayo Clinic (2000). Thinking about stopping [on-line]. Available: http://www.mayohealth.org/home?id+SK00001.
• National Cancer Institute (2001).I mind very much if you smoke [on-line]. Available:
  http://dccps.nci.nih.gov/TCRB/I_mind_if_you_smoke/mindsmo.html.
• National Safety Council (2000). Environmental tobacco smoke [on-line]. Available: http://www.nsc.org/ehc/indoor/ets.htm.
• Parrott, K and Guevin, J. (1999). Healthy indoor air for America's homes: Secondhand smoke instructional module [on-line]. Available: http://www.montana.edu:80/wwwcxair/secondhand_smoke.htm.
• Perera, F.P. (1997). Environment and cancer: Who are susceptible? Science, 278: 1068-1073.
• Quachenbush, M. (1998). Other People's Smoke [pamphlet]. Available: ETR Associates, 1-800-321-4407.
• Texas Department of Health (1997a). Secondhand smoke and kids [on-line]. Available: http://www.tdh.state.tx.us/otpc/iandh/ihbul2.htm.
• Texas Department of Health (1997b). Texas Risk Factor Report: Tobacco Use, 1995 Survey Data. Texas Department of Health, Bureau of Chronic Disease Prevention and Control, (512) 458-7200.
• Texas Department of Health (1995). Tobacco-free schools [on-line]. Available: http://www.tdh.state.tx.us/otpc/laws/sb1.htm.
• Texas Department of Health (2001). Tobacco law summary [on-line]. Available: http://www.tdh.state.tx.us/otpc/laws/sb55.htm.
• Waite, K. (1994). Secondhand smoke: Hold the smoke! [booklet]. Available: The Health Connection, 1-800-548-8700.

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