Telehealth

From Wikipedia, the free encyclopedia

Telehealth involves the distribution of health-related services and information via electronic information and telecommunication technologies. It allows long distance patient/clinician contact and care, advice, reminders, education, intervention, monitoring and remote admissions. As well as provider distance-learning; meetings, supervision, and presentations between practitioners; online information and health data management and healthcare system integration. Telehealth could include two clinicians discussing a case over video conference; a robotic surgery occurring through remote access; physical therapy done via digital monitoring instruments, live feed and application combinations; tests being forwarded between facilities for interpretation by a higher specialist; home monitoring through continuous sending of patient health data; client to practitioner online conference; or even videophone interpretation during a consult.

As the population grows and ages, and medical advances are made which prolong life, demands increase on the healthcare system. Healthcare providers are also being asked to do more, with no increase in funding, or are encouraged to move to new models of funding and care such as patient-centered or outcomes based, rather than fee-for-service. Some specific health professions already have a shortage (i.e. Speech-language pathologists). When rural settings, lack of transport, lack of mobility (i.e. In the elderly or disabled), decreased funding or lack of staffing restrict access to care, telehealth can bridge the gap.

Telehealth versus telemedicine

Telehealth is sometimes discussed interchangeably with telemedicine. The Health Resources and Services Administration distinguishes telehealth from telemedicine in its scope. According to them, telemedicine only describes remote clinical services; such as diagnosis and monitoring, while telehealth includes preventative, promotive and curative care delivery. This includes the above-mentioned non-clinical applications like administration and provider education which make telehealth the preferred modern terminology.

History

The development and history of telehealth or telemedicine (terms used interchangeably in literature) is deeply rooted in the history and development in not only technology but also society itself. Humans have long sought to relay important messages through torches, optical telegraphy, electroscopes, and wireless transmission. In the 21st century, with the advent of the internet, portable devices and other such digital devices are taking a transformative role in healthcare and its delivery.

Earliest instances

Although, traditional medicine relies on in-person care, the need and want for remote care has existed from the Roman and pre-Hippocratic periods in antiquity. The elderly and infirm who could not visit temples for medical care sent representatives to convey information on symptoms and bring home a diagnosis as well as treatment. In Africa, villagers would use smoke signals to warn neighbouring villages of disease outbreak. The beginnings of telehealth have existed through primitive forms of communication and technology.

1800s to early 1900s

As technology developed and wired communication became increasingly commonplace, the ideas surrounding telehealth began emerging. The earliest telehealth encounter can be traced to Alexander Graham Bell in 1876, when he used his early telephone as a means of getting help from his assistant Mr. Watson after he spilt acid on his trousers. Another instance of early telehealth, specifically telemedicine was reported in The Lancet in 1879. An anonymous writer described a case where a doctor successfully diagnosed a child over the telephone in the middle of the night. This Lancet issue, also further discussed the potential of Remote Patient Care in order to avoid unnecessary house visits, which were part of routine health care during the 1800s. Other instances of telehealth during this period came from the American Civil War, during which telegraphs were used to deliver mortality lists and medical care to soldiers.

From the late 1800s to the early 1900s the early foundations of wireless communication were laid down. Radios provided an easier and near instantaneous form of communication. The use of radio to deliver healthcare became accepted for remote areas. The Royal Flying Doctor Service of Australia is an example of the early adoption of radios in telehealth.

Mid-1900s to 1980s

When the American National Aeronautics and Space Administration (NASA), began plans to send astronauts into space, the need for Telemedicine became clear. In order to monitor their astronauts in space, telemedicine capabilities were built into the spacecraft as well as the first spacesuits. Additionally, during this period, telehealth and Telemedicine were promoted in different countries especially the United States and Canada.

In 1964, the Nebraska Psychiatric Institute began using television links to form two-way communication with the Norfolk State Hospital which was 112 miles away for the education and consultation purposes between clinicians in the two locations. The Logan International Airport in Boston established in-house medical stations in 1967. These stations were linked to Massachusetts General Hospital. Clinicians at the hospital would provide consultation services to patients who were at the airport. Consultations were achieved through microwave audio as well as video links.

In 1972 the Department of Health, Education and Welfare in the United States approved funding for seven telemedicine projects across different states. This funding was renewed and two further projects were funded the following year.

1980s to 1990s – maturation and renaissance

Telehealth projects underway before and during the 1980s would take off but fail to enter mainstream healthcare. As a result, this period of telehealth history is called the "maturation" stage and made way for sustainable growth. Although State funding in North America was beginning to run low, different hospitals began to launch their own telehealth initiatives. Additionally, NASA started experimenting with their ATS-3 satellite. Eventually, NASA started their SateLife/HealthNet programme which tried to increase the health services connectivity in developing countries.

2000s and onward

The combination of sustained growth, the advent of the internet and the increasing adoption of ICT in traditional methods of care spurred the revival or "renaissance" of telehealth. The diffusion of portable devices like laptops and mobile devices in everyday life made ideas surrounding telehealth more plausible. Telehealth is no longer bound within the realms of telemedicine but has expanded itself to promotion, prevention and education.

In the 2010s, integration of smart home telehealth technologies (wellness and health devices and software, Internet of Things) appears to be a growing phenomenon in the industry. Beyond that, healthcare organizations are increasingly adopting the use of self-tracking technologies, cloud-based technologies, and innovative data analytic approaches to accelerate the transformation of the healthcare system.

Methods and modalities

Telehealth requires a strong, reliable broadband connection. As broadband infrastructure has improved, telehealth usage has become more widely feasible.

Healthcare providers often begin telehealth with a needs assessment which asses hardships which can be improved by telehealth such as travel time, costs or time off work. Collaborators, such as technology companies can ease the transition.

Delivery can come within four distinct domains: live video (synchronous), store-and-forward (asynchronous), remote patient monitoring, and mobile health.

Store and forward

Store-and-forward telemedicine involves acquiring medical data (like medical images, biosignals etc.) and then transmitting this data to a doctor or medical specialist at a convenient time for assessment offline. It does not require the presence of both parties at the same time. Dermatology (cf: teledermatology), radiology, and pathology are common specialties that are conducive to asynchronous telemedicine. A properly structured medical record preferably in electronic form should be a component of this transfer. The 'store-and-forward' process requires the clinician to rely on a history report and audio/video information in lieu of a physical examination.

Remote monitoring

Telehealth Blood Pressure Monitor

 

Remote monitoring, also known as self-monitoring or testing, enables medical professionals to monitor a patient remotely using various technological devices. This method is primarily used for managing chronic diseases or specific conditions, such as heart disease, diabetes mellitus, or asthma. These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction to patients, and may be cost-effective. Examples include home-based nocturnal dialysis and improved joint management.

Real-time interactive

Electronic consultations are possible through interactive telemedicine services which provide real-time interactions between patient and provider. Videoconferencing has been used in a wide range of clinical disciplines and settings for various purposes including management, diagnosis, counseling and monitoring of patients.

Major developments

In policy

Telehealth is a modern form of health care delivery. Telehealth breaks away from traditional health care delivery by using modern telecommunication systems including wireless communication methods. Traditional health is legislated through policy to ensure the safety of medical practitioners and patients. Consequently, since telehealth is a new form of health care delivery that is now gathering momentum in the health sector, many organizations have started to legislate the use of telehealth into policy. In New Zealand, the Medical Council has a statement about telehealth on their website. This illustrates that the medical council has foreseen the importance that telehealth will have on the health system and have started to introduce telehealth legislation to practitioners along with government.

Transition to mainstream

Traditional use of telehealth services has been for specialist treatment. However, there has been a paradigm shift and telehealth is no longer considered a specialist service. This development has ensured that many access barriers are eliminated, as medical professionals are able to use wireless communication technologies to deliver health care. This is evident in rural communities. For individuals living in rural communities, specialist care can be some distance away, particularly in the next major city. Telehealth eliminates this barrier, as health professionals are able to conduct a medical consultation through the use of wireless communication technologies. However, this process is dependent on both parties having Internet access.

Telehealth allows the patient to be monitored between physician office visits which can improve patient health. Telehealth also allows patients to access expertise which is not available in their local area. This remote patient monitoring ability enables patients to stay at home longer and helps avoid unnecessary hospital time. In the long-term, this could potentially result in less burdening of the healthcare system and consumption of resources.

Technology advancement

The technological advancement of wireless communication devices is a major development in telehealth. This allows patients to self-monitor their health conditions and to not rely as much on health care professionals. Furthermore, patients are more willing to stay on their treatment plans as they are more invested and included in the process, decision-making is shared. Technological advancement also means that health care professionals are able to use better technologies to treat patients for example in surgery. Technological developments in telehealth are essential to improve health care, especially the delivery of healthcare services, as resources are finite along with an ageing population that is living longer.

Major implications and impacts

Telehealth allows multiple, different disciplines to merge and deliver a much more uniform level of care using the efficiency and accessibility of everyday technology. As telehealth proliferates mainstream healthcare and challenges notions of traditional healthcare delivery, different populations are starting to experience better quality, access and personalised care in their lives.

Health promotion

Baby Eve with Georgia for the Breastfeeding Support Project

 

Telehealth can also increase health promotion efforts. These efforts can now be more personalised to the target population and professionals can extend their help into homes or private and safe environments in which patients of individuals can practice, ask and gain health information. Health promotion using telehealth has become increasingly popular in underdeveloped countries where there are very poor physical resources available. There has been a particular push toward mHealth applications as many areas, even underdeveloped ones have mobile phone coverage.

In developed countries, health promotion efforts using telehealth have been met with some success. The Australian hands-free breastfeeding Google Glass application reported promising results in 2014. This application made in collaboration with the Australian Breastfeeding Association and a tech startup called Small World Social, helped new mothers learn how to breastfeed. Breastfeeding is beneficial to infant health and maternal health and is recommended by the World Health Organisation and health organisations all over the world. Widespread breastfeeding can prevent 820,000 infant deaths globally but the practice is often stopped prematurely or intents to do are disrupted due to lack of social support, know-how or other factors. This application gave mother's hands-free information on breastfeeding, instructions on how to breastfeed and also had an option to call a lactation consultant over Google Hangout. When the trial ended, all participants were reported to be confident in breastfeeding.

Health care quality

Theoretically, the whole health system stands to benefit from telehealth. In a UK telehealth trial done in 2011, it was reported that the cost of health could be dramatically reduced with the use of telehealth monitoring. The usual cost of in vitro fertilisation (IVF) per cycle would be around $15,000, with telehealth it was reduced to $800 per patient. In Alaska the Federal Health Care Access Network which connects 3,000 healthcare providers to communities, engaged in 160,000 telehealth consultations from 2001 and saved the state $8.5 million in travel costs for just Medicaid patients. There are indications telehealth consumes fewer resources and requires fewer people to operate it with shorter training periods to implement initiatives.

However, whether or not the standard of health care quality is increasing is quite debatable, with literature refuting such claims. Research is increasingly reporting that clinicians find the process difficult and complex to deal with. Furthermore, there are concerns around informed consent, legality issues as well as legislative issues. Although health care may become affordable with the help of technology, whether or not this care will be "good" is the issue.

Economic evaluations

Due to its digital nature it is often assumed that telehealth saves the health system money. However, the evidence to support this is varied. When conducting economic evaluations of telehealth services, the individuals evaulating them need to be aware of potential outcomes and extraclinical benefits of the telehealth service. Economic viability relies on the funding model within the country being examined (public vs private), the consumers willingness-to-pay, and the expected remuneration by the clinicians or commercial entities providing the services (examples of research on these topics from teledermoscopy in Australia).

Nonclinical uses

• Distance education including continuing medical education, grand rounds, and patient education
• Administrative uses including meetings among telehealth networks, supervision, and presentations
• Research on telehealth
• Online information and health data management
• Healthcare system integration
• Asset identification, listing, and patient to asset matching, and movement
• Overall healthcare system management
• Patient movement and remote admission

Limitations and restrictions

While many branches of medicine have wanted to fully embrace telehealth for a long time, there are certain risks and barriers which bar the full amalgamation of telehealth into best practice. For a start, it is dubious as to whether a practitioner can fully leave the "hands-on" experience behind. Although it is predicted that telehealth will replace many consultations and other health interactions, it cannot yet fully replace a physical examination, this is particularly so in diagnostics, rehabilitation or mental health.

The benefits posed by telehealth challenge the normative means of healthcare delivery set in both legislation and practice. Therefore, the growing prominence of telehealth is starting to underscore the need for updated regulations, guidelines and legislation which reflect the current and future trends of healthcare practices. Telehealth enables timely and flexible care to patients wherever they may be; although this is a benefit, it also poses threats to privacy, safety, medical licensing and reimbursement. When a clinician and patient are in different locations, it is difficult to determine which laws apply to the context. Once healthcare crosses borders different state bodies are involved in order to regulate and maintain the level of care that is warranted to the patient or telehealth consumer. As it stands, telehealth is complex with many grey areas when put into practice especially as it crosses borders. This effectively limits the potential benefits of telehealth.

An example of these limitations include the current American reimbursement infrastructure, where Medicare will reimburse for telehealth services only when a patient is living in an area where specialists are in shortage, or in particular rural counties. The area is defined by whether it is a medical facility as opposed to a patient's' home. The site that the practitioner is in, however, is unrestricted. Medicare will only reimburse live video (synchronous) type services, not store-and-forward, mhealth or remote patient monitoring (if it does not involve live-video). Some insurers currently will reimburse telehealth, but not all yet. So providers and patients must go to the extra effort of finding the correct insurers before continuing. Again in America, states generally tend to require that clinicians are licensed to practice in the surgery' state, therefore they can only provide their service if licensed in an area that they do not live in themselves.

More specific and widely reaching laws, legislations and regulations will have to evolve with the technology. They will have to be fully agreed upon, for example, will all clinicians need full licensing in every community they provide telehealth services too, or could there be a limited use telehealth licence? Would the limited use licence cover all potential telehealth interventions, or only some? Who would be responsible if an emergency was occurring and the practitioner could not provide immediate help – would someone else have to be in the room with the patient at all consult times? Which state, city or country would the law apply in when a breach or malpractice occurred?

A major legal action prompt in telehealth thus far has been issues surrounding online prescribing and whether an appropriate clinician-patient relationship can be established online to make prescribing safe, making this an area that requires particular scrutiny. It may be required that the practitioner and patient involved must meet in person at least once before online prescribing can occur, or that at least a live-video conference must occur, not just impersonal questionnaires or surveys to determine need.

Ethical issues

Informed consent is another issue – should the patient give informed consent to receive online care before it starts? Or will it be implied if it is care that can only practically be given over distance? When telehealth includes the possibility for technical problems such as transmission errors or security breaches or storage which impact on ability to communicate, it may be wise to obtain informed consent in person first, as well as having backup options for when technical issues occur. In person, a patient can see who is involved in their care (namely themselves and their clinician in a consult), but online there will be other involved such as the technology providers, therefore consent may need to involve disclosure of anyone involved in the transmission of the information and the security that will keep their information private, and any legal malpractice cases may need to involve all of those involved as opposed to what would usually just be the practitioner.

The state of the market

The rate of adoption of telehealth services in any jurisdiction is frequently influenced by factors such as the adequacy and cost of existing conventional health services in meeting patient needs; the policies of governments and/or insurers with respect to coverage and payment for telehealth services; and medical licensing requirements that may inhibit or deter the provision of telehealth second opinions or primary consultations by physicians.

Projections for the growth of the telehealth market are optimistic, and much of this optimism is predicated upon the increasing demand for remote medical care. According to a recent survey, nearly three-quarters of U.S. consumers say they would use telehealth. At present, several major companies along with a bevvy of startups are working to develop a leading presence in the field. 

In the UK, the Government's Care Services minister, Paul Burstow, has stated that telehealth and telecare would be extended over the next five years (2012–2017) to reach three million people.

Developing countries

For developing countries, telemedicine and eHealth can be the only means of healthcare provision in remote areas. For example, the difficult financial situation in many African states and lack of trained health professionals has meant that the majority of the people in sub-Saharan Africa are badly disadvantaged in medical care, and in remote areas with low population density, direct healthcare provision is often very poor However, provision of telemedicine and eHealth from urban centres or from other countries is hampered by the lack of communications infrastructure, with no landline phone or broadband internet connection, little or no mobile connectivity, and often not even a reliable electricity supply.

The Satellite African eHEalth vaLidation (SAHEL) demonstration project has shown how satellite broadband technology can be used to establish telemedicine in such areas. SAHEL was started in 2010 in Kenya and Senegal, providing self-contained, solar-powered internet terminals to rural villages for use by community nurses for collaboration with distant health centres for training, diagnosis and advice on local health issues.

In 2014, the government of Luxembourg, along with satellite operator, SES and NGOs, Archemed, Fondation Follereau, Friendship Luxembourg, German Doctors and Médecins Sans Frontières, established SATMED, a multilayer eHealth platform to improve public health in remote areas of emerging and developing countries, using the Emergency.lu disaster relief satellite platform and the Astra 2G TV satellite. SATMED was first deployed in response to a report in 2014 by German Doctors of poor communications in Sierra Leone hampering the fight against Ebola, and SATMED equipment arrived in the Serabu clinic in Sierra Leone in December 2014. In June 2015 SATMED was deployed at Maternité Hospital in Ahozonnoude, Benin to provide remote consultation and monitoring, and is the only effective communication link between Ahozonnoude, the capital and a third hospital in Allada, since land routes are often inaccessible due to flooding during the rainy season.

Passive smoking

From Wikipedia, the free encyclopedia

Tobacco smoke in an Irish pub before a smoking ban came into effect on March 29, 2004

 

Passive smoking is the inhalation of smoke, called second-hand smoke (SHS), or environmental tobacco smoke (ETS), by persons other than the intended "active" smoker. It occurs when tobacco smoke enters an environment, causing its inhalation by people within that environment. Exposure to second-hand tobacco smoke causes disease, disability, and death. The health risks of second-hand smoke are a matter of scientific consensus. These risks have been a major motivation for smoke-free laws in workplaces and indoor public places, including restaurants, bars and night clubs, as well as some open public spaces.

Concerns around second-hand smoke have played a central role in the debate over the harms and regulation of tobacco products. Since the early 1970s, the tobacco industry has viewed public concern over second-hand smoke as a serious threat to its business interests. Harm to bystanders was perceived as a motivator for stricter regulation of tobacco products. Despite the industry's awareness of the harms of second-hand smoke as early as the 1980s, the tobacco industry coordinated a scientific controversy with the purpose of stopping regulation of their products.

Effects

Second-hand smoke causes many of the same diseases as direct smoking, including cardiovascular diseases, lung cancer, and respiratory diseases. These diseases include:

• Cancer:
  • General: overall increased risk; reviewing the evidence accumulated on a worldwide basis, the International Agency for Research on Cancer concluded in 2004 that "Involuntary smoking (exposure to secondhand or 'environmental' tobacco smoke) is carcinogenic to humans."
  • Lung cancer: passive smoking is a risk factor for lung cancer. In the United States passive smoke is estimated to cause more than 7,000 deaths from lung cancer a year among non-smokers.
  • Breast cancer: The California Environmental Protection Agency concluded in 2005 that passive smoking increases the risk of breast cancer in younger, primarily premenopausal females by 70% and the US Surgeon General has concluded that the evidence is "suggestive," but still insufficient to assert such a causal relationship. In contrast, the International Agency for Research on Cancer concluded in 2004 that there was "no support for a causal relation between involuntary exposure to tobacco smoke and breast cancer in never-smokers." A 2015 meta-analysis found that the evidence that passive smoking moderately increased the risk of breast cancer had become "more substantial than a few years ago."
  • Pancreatic cancer: A 2012 meta-analysis found no evidence that passive smoking was associated with an increased risk of pancreatic cancer.
  • Cervical cancer: A 2015 overview of systematic reviews found that exposure to second-hand smoke increased the risk of cervical cancer.
  • Bladder cancer: A 2016 systematic review and meta-analysis found that secondhand smoke exposure was associated with a significant increase in the risk of bladder cancer.
• Circulatory system: risk of heart disease, reduced heart rate variability.
  • Epidemiological studies have shown that both active and passive cigarette smoking increase the risk of atherosclerosis.
  • Passive smoking is strongly associated with an increased risk of stroke, and this increased risk is disproportionately high at low levels of exposure.
• Lung problems:
  • Risk of asthma.
  • Risk of chronic obstructive pulmonary disease (COPD)
  • According to a 2015 review, passive smoking may increase the risk of tuberculosis infection and accelerate the progression of the disease, but the evidence remains weak.
  • The majority of studies on the association between secondhand smoke exposure and sinusitis have found a significant association between the two.
• Cognitive impairment and dementia: Exposure to secondhand smoke may increase the risk of cognitive impairment and dementia in adults 50 and over. Children exposed to second-hand smoke show reduced vocabulary and reasoning skills when compared with non-exposed children as well as more general cognitive and intellectual deficits.
• Mental health: Exposure to secondhand smoke is associated with an increased risk of depressive symptoms.
• During pregnancy:
  • Low birth weight.
  • Premature birth (Note that evidence of the causal link is described only as "suggestive" by the US Surgeon General in his 2006 report.) Laws limiting smoking decrease premature births.
  • Stillbirth and congenital malformations in children
  • Recent studies comparing females exposed to Environmental Tobacco Smoke and non-exposed females, demonstrate that females exposed while pregnant have higher risks of delivering a child with congenital abnormalities, longer lengths, smaller head circumferences, and low birth weight.
• General:
  • Worsening of asthma, allergies, and other conditions. A 2014 systematic review and meta-analysis found that passive smoking was associated with a slightly increased risk of allergic diseases among children and adolescents; the evidence for an association was weaker for adults.
  • Type 2 diabetes. It remains unclear whether the association between passive smoking and diabetes is causal.
• Risk of carrying Neisseria meningitidis or Streptococcus pneumoniae.
• A possible increased risk of periodontitis.
• Overall increased risk of death in both adults, where it is estimated to kill 53,000 nonsmokers per year, making it the 3rd leading cause of preventable death in the U.S, and in children. The World Health Organization states that passive smoking causes about 600,000 deaths a year, and about 1% of the global burden of disease. As of 2017, passive smoking causes about 900,000 deaths a year, which is about 1/8 of all deaths caused by smoking.
• Skin conditions: A 2016 systematic review and meta-analysis found that passive smoking was associated with a higher rate of atopic dermatitis.

Risk to children

• Sudden infant death syndrome (SIDS). In his 2006 report, the US Surgeon General concludes: "The evidence is sufficient to infer a causal relationship between exposure to secondhand smoke and sudden infant death syndrome." Secondhand smoking has been estimated to be associated with 430 SIDS deaths in the United States annually.
• Asthma. Secondhand smoke exposure is also associated with an almost doubled risk of hospitalization for asthma exacerbation among children with asthma.
• Lung infections, also including more severe illness with bronchiolitis and bronchitis, and worse outcome, as well as increased risk of developing tuberculosis if exposed to a carrier. In the United States, it is estimated that second-hand smoke has been associated with between 150,000 and 300,000 lower respiratory tract infections in infants and children under 18 months of age, resulting in between 7,500 and 15,000 hospitalizations each year
• Impaired respiratory function and slowed lung growth
• Allergies
• Maternal passive smoking increases the risk of non-syndromic orofacial clefts by 50% among their children.
• Prenatal and childhood passive smoke exposure does not appear to increase the risk of inflammatory bowel disease.
• Learning difficulties, developmental delays, executive function problems, and neurobehavioral effects. Animal models suggest a role for nicotine and carbon monoxide in neurocognitive problems.
• An increase in tooth decay (as well as related salivary biomarkers) has been associated with passive smoking in children.
• Increased risk of middle ear infections.
• Invasive meningococcal disease.
• Maternal exposure to secondhand smoke exposure during pregnancy is associated with an increased risk of neural tube defects.
• Miscarriage: a 2014 meta-analysis found that maternal secondhand smoke exposure increased the risk of miscarriage by 11%.
• Anesthesia complications and some negative surgical outcomes.
• Sleep disordered breathing: Most studies have found a significant association between passive smoking and sleep disordered breathing in children, but further studies are needed to determine whether this association is causal.
• Adverse effects on the cardiovascular system of children.

Evidence

Exposure to secondhand smoke by age, race, and poverty level in the US.

 

Epidemiological studies show that non-smokers exposed to second-hand smoke are at risk for many of the health problems associated with direct smoking. Most of the research has come from studies of nonsmokers who are married to a smoker. Those conclusions are also backed up by further studies of workplace exposure to smoke.

In 1992, a review estimated that second-hand smoke exposure was responsible for 35,000 to 40,000 deaths per year in the United States in the early 1980s. The absolute risk increase of heart disease due to ETS was 2.2%, while the attributable risk percent was 23%. A 1997 meta-analysis found that second-hand smoke exposure increased the risk of heart disease by a quarter, and two 1999 meta-analyses reached similar conclusions.

Evidence shows that inhaled sidestream smoke, the main component of second-hand smoke, is about four times more toxic than mainstream smoke. This fact has been known to the tobacco industry since the 1980s, though it kept its findings secret. Some scientists believe that the risk of passive smoking, in particular the risk of developing coronary heart diseases, may have been substantially underestimated.

In 1997, a meta-analysis on the relationship between secondhand smoke exposure and lung cancer concluded that such exposure caused lung cancer. The increase in risk was estimated to be 24% among non-smokers who lived with a smoker. In 2000, Copas and Shi reported that there was clear evidence of publication bias in the studies included in this meta-analysis. They further concluded that after correcting for publication bias, and assuming that 40% of all studies are unpublished, this increased risk decreased from 24% to 15%. This conclusion has been challenged on the basis that the assumption that 40% of all studies are unpublished was "extreme". In 2006, Takagi et al. reanalyzed the data from this meta-analysis to account for publication bias and estimated that the relative risk of lung cancer among those exposed to secondhand smoke was 1.19, slightly lower than the original estimate. A 2000 meta-analysis found a relative risk of 1.48 for lung cancer among men exposed to secondhand smoke, and a relative risk of 1.16 among those exposed to it at work. Another meta-analysis confirmed the finding of an increased risk of lung cancer among women with spousal exposure to secondhand smoke the following year. It found a relative risk of lung cancer of 1.29 for women exposed to secondhand smoke from their spouses. A 2014 meta-analysis noted that "the association between exposure to secondhand smoke and lung cancer risk is well established."

A minority of epidemiologists have found it hard to understand how second-hand smoke, which is more diluted than actively inhaled smoke, could have an effect that is such a large fraction of the added risk of coronary heart disease among active smokers. One proposed explanation is that second-hand smoke is not simply a diluted version of "mainstream" smoke, but has a different composition with more toxic substances per gram of total particulate matter. Passive smoking appears to be capable of precipitating the acute manifestations of cardio-vascular diseases (atherothrombosis) and may also have a negative impact on the outcome of patients who suffer acute coronary syndromes.

In 2004, the International Agency for Research on Cancer (IARC) of the World Health Organization (WHO) reviewed all significant published evidence related to tobacco smoking and cancer. It concluded:

These meta-analyses show that there is a statistically significant and consistent association between lung cancer risk in spouses of smokers and exposure to second-hand tobacco smoke from the spouse who smokes. The excess risk is of the order of 20% for women and 30% for men and remains after controlling for some potential sources of bias and confounding.

Subsequent meta-analyses have confirmed these findings.

The National Asthma Council of Australia cites studies showing that second-hand smoke is probably the most important indoor pollutant, especially around young children:

• Smoking by either parent, particularly by the mother, increases the risk of asthma in children.
• The outlook for early childhood asthma is less favourable in smoking households.
• Children with asthma who are exposed to smoking in the home generally have more severe disease.
• Many adults with asthma identify ETS as a trigger for their symptoms.
• Doctor-diagnosed asthma is more common among non-smoking adults exposed to ETS than those not exposed. Among people with asthma, higher ETS exposure is associated with a greater risk of severe attacks.

In France, exposure to second-hand smoke has been estimated to cause between 3,000 and 5,000 premature deaths per year, with the larger figure cited by Prime Minister Dominique de Villepin during his announcement of a nationwide smoke-free law: "That makes more than 13 deaths a day. It is an unacceptable reality in our country in terms of public health."

There is good observational evidence that smoke-free legislation reduces the number of hospital admissions for heart disease.

Risk level

The International Agency for Research on Cancer of the World Health Organization concluded in 2004 that there was sufficient evidence that second-hand smoke caused cancer in humans. Those who work in environments where smoke is not regulated are at higher risk. Workers particularly at risk of exposure include those in installation repair and maintenance, construction and extraction, and transportation.

The US Surgeon General, in his 2006 report, estimated that living or working in a place where smoking is permitted increases the non-smokers' risk of developing heart disease by 25–30% and lung cancer by 20–30%. In the U.S., smokers that have not quit successfully have a risk of lung cancer about 20 times higher than that of never smokers.

Biomarkers

Breath CO monitor displaying carbon monoxide concentration of an exhaled breath sample (in ppm) with corresponding percent concentration of carboxyhemoglobin displayed below.

 

Environmental tobacco smoke can be evaluated either by directly measuring tobacco smoke pollutants found in the air or by using biomarkers, an indirect measure of exposure. Carbon monoxide monitored through breath, nicotine, cotinine, thiocyanates, and proteins are the most specific biological markers of tobacco smoke exposure. Biochemical tests are a much more reliable biomarker of second-hand smoke exposure than surveys. Certain groups of people are reluctant to disclose their smoking status and exposure to tobacco smoke, especially pregnant women and parents of young children. This is due to their smoking being socially unacceptable. Also, it may be difficult for individuals to recall their exposure to tobacco smoke.

A 2007 study in the Addictive Behaviors journal found a positive correlation between second-hand tobacco smoke exposure and concentrations of nicotine and/or biomarkers of nicotine in the body. Significant biological levels of nicotine from second-hand smoke exposure were equivalent to nicotine levels from active smoking and levels that are associated with behaviour changes due to nicotine consumption.

Cotinine

Cotinine, the metabolite of nicotine, is a biomarker of second-hand smoke exposure. Typically, cotinine is measured in the blood, saliva, and urine. Hair analysis has recently become a new, noninvasive measurement technique. Cotinine accumulates in hair during hair growth, which results in a measure of long-term, cumulative exposure to tobacco smoke. Urinary cotinine levels have been a reliable biomarker of tobacco exposure and have been used as a reference in many epidemiological studies. However, cotinine levels found in the urine reflect exposure only over the preceding 48 hours. Cotinine levels of the skin, such as the hair and nails, reflect tobacco exposure over the previous three months and are a more reliable biomarker.

Carbon monoxide (CO)

Carbon monoxide monitored via breath is also a reliable biomarker of second-hand smoke exposure as well as tobacco use. With high sensitivity and specificity, it not only provides an accurate measure, but the test is also non-invasive, highly reproducible, and low in cost. Breath CO monitoring measures the concentration of CO in an exhalation in parts per million, and this can be directly correlated to the blood CO concentration (carboxyhemoglobin). Breath CO monitors can also be used by emergency services to identify patients who are suspected of having CO poisoning.

Pathophysiology

A 2004 study by the International Agency for Research on Cancer of the World Health Organization concluded that non-smokers are exposed to the same carcinogens as active smokers. Sidestream smoke contains more than 4,000 chemicals, including 69 known carcinogens. Of special concern are polynuclear aromatic hydrocarbons, tobacco-specific N-nitrosamines, and aromatic amines, such as 4-aminobiphenyl, all known to be highly carcinogenic. Mainstream smoke, sidestream smoke, and second-hand smoke contain largely the same components, however the concentration varies depending on type of smoke. Several well-established carcinogens have been shown by the tobacco companies' own research to be present at higher concentrations in sidestream smoke than in mainstream smoke.

Second-hand smoke has been shown to produce more particulate-matter (PM) pollution than an idling low-emission diesel engine. In an experiment conducted by the Italian National Cancer Institute, three cigarettes were left smoldering, one after the other, in a 60 m³ garage with a limited air exchange. The cigarettes produced PM pollution exceeding outdoor limits, as well as PM concentrations up to 10-fold that of the idling engine.

Second-hand tobacco smoke exposure has immediate and substantial effects on blood and blood vessels in a way that increases the risk of a heart attack, particularly in people already at risk. Exposure to tobacco smoke for 30 minutes significantly reduces coronary flow velocity reserve in healthy nonsmokers. Second-hand smoke is also associated with impaired vasodilation among adult nonsmokers. Second-hand smoke exposure also affects platelet function, vascular endothelium, and myocardial exercise tolerance at levels commonly found in the workplace.

Pulmonary emphysema can be induced in rats through acute exposure to sidestream tobacco smoke (30 cigarettes per day) over a period of 45 days. Degranulation of mast cells contributing to lung damage has also been observed.

The term "third-hand smoke" was recently coined to identify the residual tobacco smoke contamination that remains after the cigarette is extinguished and second-hand smoke has cleared from the air. Preliminary research suggests that by-products of third-hand smoke may pose a health risk, though the magnitude of risk, if any, remains unknown. In October 2011, it was reported that Christus St. Frances Cabrini Hospital in Alexandria, Louisiana would seek to eliminate third-hand smoke beginning in July 2012, and that employees whose clothing smelled of smoke would not be allowed to work. This prohibition was enacted because third-hand smoke poses a special danger for the developing brains of infants and small children.

In 2008, there were more than 161,000 deaths attributed to lung cancer in the United States. Of these deaths, an estimated 10% to 15% were caused by factors other than first-hand smoking; equivalent to 16,000 to 24,000 deaths annually. Slightly more than half of the lung cancer deaths caused by factors other than first-hand smoking were found in nonsmokers. Lung cancer in non-smokers may well be considered one of the most common cancer mortalities in the United States. Clinical epidemiology of lung cancer has linked the primary factors closely tied to lung cancer in non-smokers as exposure to second-hand tobacco smoke, carcinogens including radon, and other indoor air pollutants.

Opinion of public health authorities

There is widespread scientific consensus that exposure to second-hand smoke is harmful. The link between passive smoking and health risks is accepted by every major medical and scientific organisation, including:

• World Health Organization
• U.S. National Institutes of Health
• Centers for Disease Control
• United States Surgeon General
• U.S. National Cancer Institute
• United States Environmental Protection Agency
• California Environmental Protection Agency
• American Heart Association, American Lung Association, and American Cancer Society
• American Medical Association
• American Academy of Pediatrics
• Australian National Health and Medical Research Council
• United Kingdom Scientific Committee on Tobacco and Health

Public opinion

Recent major surveys conducted by the U.S. National Cancer Institute and Centers for Disease Control have found widespread public awareness that second-hand smoke is harmful. In both 1992 and 2000 surveys, more than 80% of respondents agreed with the statement that second-hand smoke was harmful. A 2001 study found that 95% of adults agreed that second-hand smoke was harmful to children, and 96% considered tobacco-industry claims that second-hand smoke was not harmful to be untruthful.

A 2007 Gallup poll found that 56% of respondents felt that second-hand smoke was "very harmful", a number that has held relatively steady since 1997. Another 29% believe that second-hand smoke is "somewhat harmful"; 10% answered "not too harmful", while 5% said "not at all harmful".

Controversy over harm

As part of its attempt to prevent or delay tighter regulation of smoking, the tobacco industry funded a number of scientific studies and, where the results cast doubt on the risks associated with second-hand smoke, sought wide publicity for those results. The industry also funded libertarian and conservative think tanks, such as the Cato Institute in the United States and the Institute of Public Affairs in Australia which criticised both scientific research on passive smoking and policy proposals to restrict smoking. New Scientist and the European Journal of Public Health have identified these industry-wide coordinated activities as one of the earliest expressions of corporate denialism. Further, they state that the disinformation spread by the tobacco industry has created a tobacco denialism movement, sharing many characteristics of other forms of denialism, such as HIV-AIDS denialism.

Industry-funded studies and critiques

Enstrom and Kabat

A 2003 study by James Enstrom and Geoffrey Kabat, published in the British Medical Journal, argued that the harms of passive smoking had been overstated. Their analysis reported no statistically significant relationship between passive smoking and lung cancer, coronary heart disease (CHD), or chronic obstructive pulmonary disease, though the accompanying editorial noted that "they may overemphasise the negative nature of their findings." This paper was widely promoted by the tobacco industry as evidence that the harms of passive smoking were unproven. The American Cancer Society (ACS), whose database Enstrom and Kabat used to compile their data, criticized the paper as "neither reliable nor independent", stating that scientists at the ACS had repeatedly pointed out serious flaws in Enstrom and Kabat's methodology prior to publication. Notably, the study had failed to identify a comparison group of "unexposed" persons.

Enstrom's ties to the tobacco industry also drew scrutiny; in a 1997 letter to Philip Morris, Enstrom requested a "substantial research commitment... in order for me to effectively compete against the large mountain of epidemiologic data and opinions that already exist regarding the health effects of ETS and active smoking." In a US racketeering lawsuit against tobacco companies, the Enstrom and Kabat paper was cited by the US District Court as "a prime example of how nine tobacco companies engaged in criminal racketeering and fraud to hide the dangers of tobacco smoke." The Court found that the study had been funded and managed by the Center for Indoor Air Research, a tobacco industry front group tasked with "offsetting" damaging studies on passive smoking, as well as by Philip Morris who stated that Enstrom's work was "clearly litigation-oriented." A 2005 paper in Tobacco Control argued that the disclosure section in the Enstrom and Kabat BMJ paper, although it met the journal's requirements, "does not reveal the full extent of the relationship the authors had with the tobacco industry."

In 2006, Enstrom and Kabat published a meta-analysis of studies regarding passive smoking and coronary heart disease in which they reported a very weak association between passive smoking and heart disease mortality. They concluded that exposure to second-hand smoke increased the risk of death from CHD by only 5%, although this analysis has been criticized for including two previous industry-funded studies that suffered from widespread exposure misclassification.

Gori

Gio Batta Gori, a tobacco industry spokesman and consultant and an expert on risk utility and scientific research, wrote in the libertarian Cato Institute's magazine Regulation that "...of the 75 published studies of ETS and lung cancer, some 70% did not report statistically significant differences of risk and are moot. Roughly 17% claim an increased risk and 13% imply a reduction of risk."

Milloy

Steven Milloy, the "junk science" commentator for Fox News and a former Philip Morris consultant, claimed that "of the 19 studies" on passive smoking "only 8— slightly more than 42%— reported statistically significant increases in heart disease incidence.."

Another component of criticism cited by Milloy focused on relative risk and epidemiological practices in studies of passive smoking. Milloy, who has a master's degree from the Johns Hopkins School of Hygiene and Public Health, argued that studies yielding relative risks of less than 2 were meaningless junk science. This approach to epidemiological analysis was criticized in the American Journal of Public Health:

A major component of the industry attack was the mounting of a campaign to establish a "bar" for "sound science" that could not be fully met by most individual investigations, leaving studies that did not meet the criteria to be dismissed as "junk science."

The tobacco industry and affiliated scientists also put forward a set of "Good Epidemiology Practices" which would have the practical effect of obscuring the link between secondhand smoke and lung cancer; the privately stated goal of these standards was to "impede adverse legislation". However, this effort was largely abandoned when it became clear that no independent epidemiological organization would agree to the standards proposed by Philip Morris et al.

Levois and Layard

In 1995, Levois and Layard, both tobacco industry consultants, published two analyses in the journal Regulatory Toxicology and Pharmacology regarding the association between spousal exposure to second-hand smoke and heart disease. Both of these papers reported no association between second-hand smoke and heart disease. These analyses have been criticized for failing to distinguish between current and former smokers, despite the fact that former smokers, unlike current ones, are not at a significantly increased risk of heart disease.

World Health Organization controversy

A 1998 study by the International Agency for Research on Cancer (IARC) on environmental tobacco smoke (ETS) found "weak evidence of a dose–response relationship between risk of lung cancer and exposure to spousal and workplace ETS."

In March 1998, before the study was published, reports appeared in the media alleging that the IARC and the World Health Organization (WHO) were suppressing information. The reports, appearing in the British Sunday Telegraph and The Economist, among other sources, alleged that the WHO withheld from publication of its own report that supposedly failed to prove an association between passive smoking and a number of other diseases (lung cancer in particular). 

In response, the WHO issued a press release stating that the results of the study had been "completely misrepresented" in the popular press and were in fact very much in line with similar studies demonstrating the harms of passive smoking. The study was published in the Journal of the National Cancer Institute in October of the same year, and concluded the authors found "no association between childhood exposure to ETS and lung cancer risk" but "did find weak evidence of a dose–response relationship between risk of lung cancer and exposure to spousal and workplace ETS." An accompanying editorial summarized:

When all the evidence, including the important new data reported in this issue of the Journal, is assessed, the inescapable scientific conclusion is that ETS is a low-level lung carcinogen.

With the release of formerly classified tobacco industry documents through the Tobacco Master Settlement Agreement, it was found (by Elisa Ong and Stanton Glantz) that the controversy over the WHO's alleged suppression of data had been engineered by Philip Morris, British American Tobacco, and other tobacco companies in an effort to discredit scientific findings which would harm their business interests. A WHO inquiry, conducted after the release of the tobacco-industry documents, found that this controversy was generated by the tobacco industry as part of its larger campaign to cut the WHO's budget, distort the results of scientific studies on passive smoking, and discredit the WHO as an institution. This campaign was carried out using a network of ostensibly independent front organizations and international and scientific experts with hidden financial ties to the industry.

EPA lawsuit

In 1993, the United States Environmental Protection Agency (EPA) issued a report estimating that 3,000 lung cancer related deaths in the United States were caused by passive smoking annually.

Philip Morris, R.J. Reynolds Tobacco Company, and groups representing growers, distributors and marketers of tobacco took legal action, claiming that the EPA had manipulated this study and ignored accepted scientific and statistical practices. 

The United States District Court for the Middle District of North Carolina ruled in favor of the tobacco industry in 1998, finding that the EPA had failed to follow proper scientific and epidemiologic practices and had "cherry picked" evidence to support conclusions which they had committed to in advance. The court stated in part, "EPA publicly committed to a conclusion before research had begun…adjusted established procedure and scientific norms to validate the Agency's public conclusion... In conducting the ETS Risk Assessment, disregarded information and made findings on selective information; did not disseminate significant epidemiologic information; deviated from its Risk Assessment Guidelines; failed to disclose important findings and reasoning…"

In 2002, the EPA successfully appealed this decision to the United States Court of Appeals for the Fourth Circuit. The EPA's appeal was upheld on the preliminary grounds that their report had no regulatory weight, and the earlier finding was vacated.

In 1998, the U.S. Department of Health and Human Services, through the publication by its National Toxicology Program of the 9th Report on Carcinogens, listed environmental tobacco smoke among the known carcinogens, observing of the EPA assessment that "The individual studies were carefully summarized and evaluated."

Tobacco-industry funding of research

The tobacco industry's role in funding scientific research on second-hand smoke has been controversial. A review of published studies found that tobacco-industry affiliation was strongly correlated with findings exonerating second-hand smoke; researchers affiliated with the tobacco industry were 88 times more likely than independent researchers to conclude that second-hand smoke was not harmful. In a specific example which came to light with the release of tobacco-industry documents, Philip Morris executives successfully encouraged an author to revise his industry-funded review article to downplay the role of second-hand smoke in sudden infant death syndrome. The 2006 U.S. Surgeon General's report criticized the tobacco industry's role in the scientific debate:

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.

This strategy was outlined at an international meeting of tobacco companies in 1988, at which Philip Morris proposed to set up a team of scientists, organized by company lawyers, to "carry out work on ETS to keep the controversy alive." All scientific research was subject to oversight and "filtering" by tobacco-industry lawyers:

Philip Morris then expect the group of scientists to operate within the confines of decisions taken by PM scientists to determine the general direction of research, which apparently would then be 'filtered' by lawyers to eliminate areas of sensitivity.

Philip Morris reported that it was putting "...vast amounts of funding into these projects... in attempting to coordinate and pay so many scientists on an international basis to keep the ETS controversy alive."

Tobacco industry response

Measures to tackle second-hand smoke pose a serious economic threat to the tobacco industry, having broadened the definition of smoking beyond a personal habit to something with a social impact. In a confidential 1978 report, the tobacco industry described increasing public concerns about second-hand smoke as "the most dangerous development to the viability of the tobacco industry that has yet occurred." In United States of America v. Philip Morris et al., the District Court for the District of Columbia found that the tobacco industry "... recognized from the mid-1970s forward that the health effects of passive smoking posed a profound threat to industry viability and cigarette profits," and that the industry responded with "efforts to undermine and discredit the scientific consensus that ETS causes disease."

Accordingly, the tobacco industry have developed several strategies to minimise the impact on their business:

• The industry has sought to position the second-hand smoke debate as essentially concerned with civil liberties and smokers' rights rather than with health, by funding groups such as FOREST.
• Funding bias in research; in all reviews of the effects of second-hand smoke on health published between 1980 and 1995, the only factor associated with concluding that second-hand smoke is not harmful was whether an author was affiliated with the tobacco industry. However, not all studies that failed to find evidence of harm were by industry-affiliated authors.
• Delaying and discrediting legitimate research (see for an example of how the industry attempted to discredit Takeshi Hirayama's landmark study, and for an example of how it attempted to delay and discredit a major Australian report on passive smoking)
• Promoting "good epidemiology" and attacking so-called junk science (a term popularised by industry lobbyist Steven Milloy): attacking the methodology behind research showing health risks as flawed and attempting to promote sound science. Ong & Glantz (2001) cite an internal Phillip Morris memo giving evidence of this as company policy.
• Creation of outlets for favourable research. In 1989, the tobacco industry established the International Society of the Built Environment, which published the peer-reviewed journal Indoor and Built Environment. This journal did not require conflict-of-interest disclosures from its authors. With documents made available through the Master Settlement, it was found that the executive board of the society and the editorial board of the journal were dominated by paid tobacco-industry consultants. The journal published a large amount of material on passive smoking, much of which was "industry-positive".

Citing the tobacco industry's production of biased research and efforts to undermine scientific findings, the 2006 U.S. Surgeon General's report concluded that the industry had "attempted to sustain controversy even as the scientific community reached consensus... industry documents indicate that the tobacco industry has engaged in widespread activities... that have gone beyond the bounds of accepted scientific practice." The U.S. District Court, in U.S.A. v. Philip Morris et al., found that "...despite their internal acknowledgment of the hazards of secondhand smoke, Defendants have fraudulently denied that ETS causes disease."

Position of major tobacco companies

The positions of major tobacco companies on the issue of second-hand smoke is somewhat varied. In general, tobacco companies have continued to focus on questioning the methodology of studies showing that second-hand smoke is harmful. Some (such as British American Tobacco and Philip Morris) acknowledge the medical consensus that second-hand smoke carries health risks, while others continue to assert that the evidence is inconclusive. Several tobacco companies advocate the creation of smoke-free areas within public buildings as an alternative to comprehensive smoke-free laws.

US racketeering lawsuit against tobacco companies

On September 22, 1999, the U.S. Department of Justice filed a racketeering lawsuit against Philip Morris and other major cigarette manufacturers. Almost 7 years later, on August 17, 2006 U.S. District Court Judge Gladys Kessler found that the Government had proven its case and that the tobacco company defendants had violated the Racketeer Influenced Corrupt Organizations Act (RICO). In particular, Judge Kessler found that PM and other tobacco companies had

• conspired to minimize, distort and confuse the public about the health hazards of smoking;
• publicly denied, while internally acknowledging, that second-hand tobacco smoke is harmful to nonsmokers, and
• destroyed documents relevant to litigation.

The ruling found that tobacco companies undertook joint efforts to undermine and discredit the scientific consensus that second-hand smoke causes disease, notably by controlling research findings via paid consultants. The ruling also concluded that tobacco companies were fraudulently continuing to deny the health effects of ETS exposure.

On May 22, 2009, a three-judge panel of the U.S. Court of Appeals for the District of Columbia Circuit unanimously upheld the lower court's 2006 ruling.

Smoke-free laws

As a consequence of the health risks associated with second-hand smoke, smoke-free regulations in indoor public places, including restaurants, cafés, and nightclubs have been introduced in a number of jurisdictions, at national or local level, as well as some outdoor open areas. Ireland was the first country in the world to institute a comprehensive national smoke-free law on smoking in all indoor workplaces on 29 March 2004. Since then, many others have followed suit. The countries which have ratified the WHO Framework Convention on Tobacco Control (FCTC) have a legal obligation to implement effective legislation "for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places." (Article 8 of the FCTC) The parties to the FCTC have further adopted Guidelines on the Protection from Exposure to Second-hand Smoke which state that "effective measures to provide protection from exposure to tobacco smoke ... require the total elimination of smoking and tobacco smoke in a particular space or environment in order to create a 100% smoke-free environment."

Opinion polls have shown considerable support for smoke-free laws. In June 2007, a survey of 15 countries found 80% approval for smoke-free laws. A survey in France, reputedly a nation of smokers, showed 70% support.

Effects

Smoking bans by governments result in decreased harm from second hand smoke including decrease cardiovascular disease. In the first 18 months after the town of Pueblo, Colorado enacted a smoke-free law in 2003, hospital admissions for heart attacks dropped 27%. Admissions in neighbouring towns without smoke-free laws showed no change, and the decline in heart attacks in Pueblo was attributed to the resulting reduction in second-hand smoke exposure. A 2004 smoking ban instituted in Massachusetts workplaces decreased workers' secondhand smoke exposure from 8% of workers in 2003 to 5.4% of workers in 2010. A 2016 review also found benefits of decrease exposure to smoke from specific location policies.

In 2001, a systematic review for the Guide to Community Preventative Services acknowledged strong evidence of the effectiveness of smoke-free policies and restrictions in reducing expose to second-hand smoke. A follow up to this review, identified the evidence on which the effectiveness of smoking bans reduced the prevalence of tobacco use. Articles published until 2005, were examined to further support this evidence. The examined studies provided sufficient evidence that smoke-free policies reduce tobacco use among workers when implemented in worksites or by communities.

While a number of studies funded by the tobacco industry have claimed a negative economic impact from smoke-free laws, no independently funded research has shown any such impact. A 2003 review reported that independently funded, methodologically sound research consistently found either no economic impact or a positive impact from smoke-free laws.

Air nicotine levels were measured in Guatemalan bars and restaurants before and after an implemented smoke-free law in 2009. Nicotine concentrations significantly decreased in both the bars and restaurants measured. Also, the employees support for a smoke-free workplace substantially increased in the post-implementation survey compared to pre-implementation survey. The result of this smoke-free law provides a considerably more healthy work environment for the staff.

Public opinion

Recent surveys taken by the Society for Research on Nicotine and Tobacco demonstrates supportive attitudes of the public, towards smoke-free policies in outdoor areas. A vast majority of the public supports restricting smoking in various outdoor settings. The respondents reasons for supporting the policies were for varying reasons such as, litter control, establishing positive smoke-free role models for youth, reducing youth opportunities to smoke, and avoiding exposure to secondhand smoke.

Alternative forms

Alternatives to smoke-free laws have also been proposed as a means of harm reduction, particularly in bars and restaurants. For example, critics of smoke-free laws cite studies suggesting ventilation as a means of reducing tobacco smoke pollutants and improving air quality. Ventilation has also been heavily promoted by the tobacco industry as an alternative to outright bans, via a network of ostensibly independent experts with often undisclosed ties to the industry. However, not all critics have connections to the industry. 

The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) officially concluded in 2005 that while completely isolated smoking rooms do eliminate the risk to nearby non-smoking areas, smoking bans are the only means of completely eliminating health risks associated with indoor exposure. They further concluded that no system of dilution or cleaning was effective at eliminating risk. The U.S. Surgeon General and the European Commission Joint Research Centre have reached similar conclusions. The implementation guidelines for the WHO Framework Convention on Tobacco Control states that engineering approaches, such as ventilation, are ineffective and do not protect against second-hand smoke exposure. However, this does not necessarily mean that such measures are useless in reducing harm, only that they fall short of the goal of reducing exposure completely to zero. 

Others have suggested a system of tradable smoking pollution permits, similar to the cap-and-trade pollution permits systems used by the Environmental Protection Agency in recent decades to curb other types of pollution. This would guarantee that a portion of bars/restaurants in a jurisdiction will be smoke-free, while leaving the decision to the market.

In animals

Multiple studies have been conducted to determine the carcinogenicity of environmental tobacco smoke to animals. These studies typically fall under the categories of simulated environmental tobacco smoke, administering condensates of sidestream smoke, or observational studies of cancer among pets. 

To simulate environmental tobacco smoke, scientists expose animals to sidestream smoke, that which emanates from the cigarette's burning cone and through its paper, or a combination of mainstream and sidestream smoke. The IARC monographs conclude that mice with prolonged exposure to simulated environmental tobacco smoke, that is 6hrs a day, 5 days a week, for five months with a subsequent 4 month interval before dissection, will have significantly higher incidence and multiplicity of lung tumors than with control groups. 

The IARC monographs concluded that sidestream smoke condensates had a significantly higher carcinogenic effect on mice than did mainstream smoke condensates.

Observational studies

Second-hand smoke is popularly recognised as a risk factor for cancer in pets. A study conducted by the Tufts University School of Veterinary Medicine and the University of Massachusetts Amherst linked the occurrence of feline oral cancer to exposure to environmental tobacco smoke through an overexpression of the p53 gene. Another study conducted at the same universities concluded that cats living with a smoker were more likely to get feline lymphoma; the risk increased with the duration of exposure to secondhand smoke and the number of smokers in the household. A study by Colorado State University researchers, looking at cases of canine lung cancer, was generally inconclusive, though the authors reported a weak relation for lung cancer in dogs exposed to environmental tobacco smoke. The number of smokers within the home, the number of packs smoked in the home per day, and the amount of time that the dog spent within the home had no effect on the dog's risk for lung cancer.

Terminology

As of 2003, "secondhand smoke" was the term most used to refer to other people's smoke in the English-language media. Other terms used include "environmental tobacco smoke", while "involuntary smoking" and "passive smoking" are used to refer to exposure to secondhand smoke. The term "environmental tobacco smoke" can be traced back to a 1974 industry-sponsored meeting held in Bermuda, while the term "passive smoking" was first used in the title of a scientific paper in 1970. The Surgeon General of the United States prefers to use the phrase "secondhand smoke" rather than "environmental tobacco smoke", stating that "The descriptor "secondhand" captures the involuntary nature of the exposure, while "environmental" does not." Most researchers consider the term "passive smoking" to be synonymous with "secondhand smoke". In contrast, a 2011 commentary in Environmental Health Perspectives argued that research into "thirdhand smoke" renders it inappropriate to refer to passive smoking with the term "secondhand smoke", which the authors stated constitutes a pars pro toto.