0
April 24, 1996, Vol 275, No. 16 >
ARTICLE | April 24, 1996

Exposure of the US Population to Environmental Tobacco Smoke: Title and subTitle BreakThe Third National Health and Nutrition Examination Survey, 1988 to 1991 FREE

James L. Pirkle, MD, PhD; Katherine M. Flegal, PhD, MPH; John T. Bernert, PhD; Debra J. Brody, MPH; Ruth A. Etzel, MD, PhD; Kurt R. Maurer, PhD
[+] Author Affiliations

Reprints: James L. Pirkle, MD, Mailstop F20, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA 30341-3724.


JAMA. 1996;275(16):1233-1240. doi:10.1001/jama.1996.03530400021033
Text Size: A A A
Published online
Article
References

Objective.  —To estimate the extent of exposure of the US population to environmental tobacco smoke and the contribution of the home and workplace environment to environmental tobacco smoke exposure.

Design.  —Nationally representative cross-sectional survey including questionnaire information from persons aged 2 months and older (n=16 818) and measurements of serum cotinine (a metabolite of nicotine) from persons aged 4 years and older (n=10 642).

Setting/Participants.  —Participants in the Third National Health and Nutrition Examination Survey, October 25, 1988, to October 21, 1991.

Results.  —Of US children aged 2 months to 11 years, 43% lived in a home with at least 1 smoker, and 37% of adult non—tobacco users lived in a home with at least 1 smoker or reported environmental tobacco smoke exposure at work. Serum cotinine levels indicated more widespread exposure to nicotine. Of non—tobacco users, 87.9% had detectable levels of serum cotinine. Both the number of smokers in the household and the hours exposed at work were significantly and independently associated (P<.001, multiple regression t test) with increased serum cotinine levels. Serum cotinine levels of children, non-Hispanic blacks, and males indicated that these groups had higher exposure to environmental tobacco smoke. Dietary variables showed no consistent association with serum cotinine levels, and dietary contribution to serum cotinine level, if any, appeared to be extremely small.

Conclusions.  —The high proportion of the population with detectable serum cotinine levels indicates widespread exposure to environmental tobacco smoke in the US population. Both the home and workplace environments significantly contribute to environmental tobacco smoke exposure in the United States.(JAMA. 1996;275:1233-1240)

REFERENCES

1 +
Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders . Washington, DC: Environmental Protection Agency, Office of Air and Radiation; 1992;. Environmental Protection Agency publication EPA/600/6-90/006F.
2 +
National Research Council. Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects . Washington, DC: National Academy Press; 1986;.
3 +
US Dept of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of t he Surgeon General . Washington DC: US Dept of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office of Smoking and Health; 1986;. US Dept of Health and Human Services publication PHS 87-8398.
4 +
Fontham ETH, Correa P, Reynolds P, et al.  Environmental tobacco smoke and lung cancer in nonsmoking women: a multicenter study. JAMA . 1994;;271:1752-1759.
5 +
Borland R, Pierce JP, Burns DM, et al.  Protection from environmental tobacco smoke in California. JAMA . 1992;;268:749-752.
6 +
Stockwell HG, Goldman AL, Lyman GH, et al.  Environmental tobacco smoke and lung cancer risk in nonsmoking women. J Natl Cancer Inst . 1992;; 84:1417-1422.
7 +
Riboli E, Preston-Martin S, Saracci R, et al.  Exposure of nonsmoking women to environmental tobacco smoke: a 10-country collaborative study. Cancer Causes Control . 1990;;1:243-252.
8 +
Wagenknecht LE, Manolio TA, Sidney S, et al.  Environmental tobacco smoke exposure as determined by cotinine in black and white young adults: the CARDIA Study. Environ Res . 1993;;63:39-46.
9 +
Watts RR, Langone JJ, Knight GJ, Lewtas J.  Cotinine analytical workshop report: consideration of analytical methods for determining cotinine in human body fluids as a measure of passive exposure to tobacco smoke. Environ Health Perspect . 1990;;84:173-182.
10 +
Wall MA, Johnson J, Jacob P, Benowitz NL.  Cotinine in the serum, saliva and urine of nonsmokers, passive smokers and active smokers. Am J Public Health . 1988;;78:699-701.
11 +
Jarvis MJ, Russell MAH, Benowitz NL, Feyerabend C.  Elimination of cotinine from body fluids: implications for noninvasive measurement of tobacco smoke exposure. Am J Public Health . 1988;; 78:696-698.
12 +
Haley NJ, Axelrod CM, Tilton KA.  Validation of self-reported smoking behavior: biochemical analyses of cotinine and thiocyanate. Am J Public Health . 1988;;73:1204-1207.
13 +
Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Vesey C, Saloojee Y.  Biochemical markers of smoke absorption and self-reported exposure to passive smoking. J Epidemiol Community Health . 1984;; 38:335-339.
14 +
Etzel RA.  A review of the use of saliva cotinine as a marker of tobacco smoke exposure. Prev Med . 1990;;19:190-197.
15 +
Cummings SR, Richard RJ.  Optimum cutoff points for biochemical validation of smoking status. Am J Public Health . 1988;;78:574-575.
16 +
Woodward M, Tunstall-Pedoe H.  An iterative technique for identifying smoking deceivers with application to the Scottish Heart Health Study. Prev Med . 1992;;21:88-97.
17 +
Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Ve sey C, Saloojee Y.  Comparison of tests used to distinguish smokers from nonsmokers. Am J Public Health . 1987;;77:1435-1438.
18 +
Woodward M, Tunstall-Pedoe H, Smith WCS, Tavendale R.  Smoking characteristics and inhalation biochemistry in the Scottish population. J Clin Epidemiol . 1991;;44:1405-1410.
19 +
Tunstall-Pedoe H, Woodward M, Brown CA.  Tea drinking, passive smoking, smoking deception and serum cotinine in the Scottish Heart Health Study. J Clin Epidemiol . 1991;;44:1411-1414.
20 +
Emmons KM, Abrams DB, Marshall R, et al.  An evaluation of the relationship between self-report and biochemical measures of environmental tobacco smoke exposure. Prev Med . 1994;;23:35-39.
21 +
Cummings KM, Markello SJ, Mahoney M, et al.  Measurement of current exposure to environmental tobacco smoke. Arch Environ Health . 1990;;45: 74-79.
22 +
Patrick DL, Cheadle A, Thomson DC, et al.  The validity of self-reported smoking: a review and meta-analysis. Am J Public Health . 1994;;84:1086-1093.
23 +
Benowitz NL, Perez-Stable E, Herrera B, Jacob P.  African American—Caucasian differences in nicotine and cotinine metabolism. Clin Pharmacol Ther . 1995;;57:159.
24 +
Benowitz NL, Kuyt F, Jacob P, Jones RT, Osman AL.  Cotinine disposition and effects. Clin Pharmacol Ther . 1983;;34:604-611.
25 +
Langone JJ, Gjika HB, Van Vunakis H.  Nicotine and its metabolites: radioimmunoassays for nicotine and cotinine. Biochemistry . 1973;;12:5025-5030.
26 +
Greenberg RA, Haley NJ, Etzel RA, Loda FA.  Measuring the exposure of infants to tobacco smoke: nicotine and cotinine in urine and saliva. N Engl J Med . 1984;;310:1075-1078.
27 +
Matsukura S, Taminato T, Kitano N, et al.  Effects of environmental tobacco smoke on urinary cotinine excretion in nonsmokers: evidence for passive smoking. N Engl J Med . 1984;;311:828-832.
28 +
Wilcox RG, Hughes J, Roland J.  Verification of smoking history in patients after infarction using urinary nicotine and cotinine measurements. BMJ . 1979;;2:1026-1028.
29 +
Benowitz NL, Kuyt F, Jacob P, Jones RT, Osman AL.  Cotinine disposition and effects. Clin Pharmacol Ther . 1983;;34:604-611.
30 +
Castro A, Monji N.  Dietary nicotine and its significance in studies on tobacco smoking. Biochem Arch . 1986;;2:91-97.
31 +
Ezzati TM, Massey JT, Waksberg J, Chu A, Maurer KR.  Sample design: Third National Health and Nutrition Examination Survey. Vital Health Stat 2 . 1992;; No. (113) .
32 +
National Center for Health Statistics.  Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-1994. Vital Health Stat . 1994;;1 ( (32) ).
33 +
Forthofer RN.  Investigation of nonresponse bias in NHANES II. Am J Epidemiol . 1983;;117: 507-515.
34 +
Flegal KM, Ezzati TM, Harris MI, et al.  Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in US population aged 20-74 yrs. Diabetes . 1987;;36:523-534.
35 +
Davis RA, Stiles MF, deBethizy JD, Reynolds JH.  Dietary nicotine: a source of urinary cotinine. Food Chem Toxicol . 1991;;29:821-827.
36 +
Domino EF, Hornback E, Demana T.  The nicotine content of common vegetables. N Engl J Med . 1993;;329:437.
37 +
Sheen SJ.  Detection of nicotine in foods and plant materials. J Food Sci . 1988;;53:1572-1573.
38 +
Bernert JT, Sosnoff C, Turner WE, et al.  Development of a rapid and sensitive method for serum cotinine analysis as a marker of exposure to environmental tobacco smoke. Clin Chem . 1994;;40: 1075.
39 +
Taylor JK. Quality Control of Chemical Measurements . Chelsea, Mich: Lewis Publishers; 1987;.
40 +
Long GL, Winefordner JD.  Limit of detection: a closer look at the IUPAC definition. Anal Chem . 1983;;55:712a-719a.
41 +
SAS Institute Inc. SAS Language: Reference, Version 6 . Cary, NC: SAS Institute Inc; 1990;.
42 +
Shah BV, Barnwell BG, Hunt PN, Lavange LM. SUDAAN User's Manual, Release 5.50 . Research Triangle Park, NC: Research Triangle Institute; 1991;.
43 +
Repace JL.  Won't mislead on passive smoking.... BMJ . 1994;;308:61.
44 +
Jarvis MJ.  Unless subjects eat 90 kg tomatoes a day. BMJ . 1994;;308:62.
45 +
Pattishall EN, Strope GL, Etzel RA, Helms RW, Haley NJ, Denny FW.  Serum cotinine as a measure of tobacco smoke exposure in children. AJDC . 1985;;139:1101-1104.
46 +
Overpeck MD, Moss AJ.  Children's exposure to environmental cigarette smoke before and after birth: health of our nation's children, United States, 1988.  In: Advance Data From Vital and Health Statistics . Hyattsville, Md: National Center for Health Statistics; 1991;:No. 202.
47 +
Hammond SK, Sorensen G, Youngstrom R, Ockene JK.  Occupational exposure to environmental tobacco smoke. JAMA . 1995;;274:956-960.
48 +
Hinds WC, First MW.  Concentrations of nicotine and tobacco smoke in public places. N Engl J Med . 1975;;292:844-845.
49 +
Muramatsu M, Umemura S, Okada T, Tomita H.  Estimation of personal exposure to tobacco smoke with a newly developed nicotine personal monitor. Environ Res . 1984;;35:218-227.
50 +
Jenkins PL, Phillips TJ, Mulberg EJ, Hui SP.  Activity patterns of Californians: use of and proximity to indoor pollutant sources. Atmos Environ . 1992;;26A:2141-2148.
51 +
Kabat GC, Wynder EL.  Lung cancer in nonsmokers. Cancer . 1984;;53:1214-1221.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders . Washington, DC: Environmental Protection Agency, Office of Air and Radiation; 1992;. Environmental Protection Agency publication EPA/600/6-90/006F.
2 +
National Research Council. Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects . Washington, DC: National Academy Press; 1986;.
3 +
US Dept of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of t he Surgeon General . Washington DC: US Dept of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office of Smoking and Health; 1986;. US Dept of Health and Human Services publication PHS 87-8398.
4 +
Fontham ETH, Correa P, Reynolds P, et al.  Environmental tobacco smoke and lung cancer in nonsmoking women: a multicenter study. JAMA . 1994;;271:1752-1759.
5 +
Borland R, Pierce JP, Burns DM, et al.  Protection from environmental tobacco smoke in California. JAMA . 1992;;268:749-752.
6 +
Stockwell HG, Goldman AL, Lyman GH, et al.  Environmental tobacco smoke and lung cancer risk in nonsmoking women. J Natl Cancer Inst . 1992;; 84:1417-1422.
7 +
Riboli E, Preston-Martin S, Saracci R, et al.  Exposure of nonsmoking women to environmental tobacco smoke: a 10-country collaborative study. Cancer Causes Control . 1990;;1:243-252.
8 +
Wagenknecht LE, Manolio TA, Sidney S, et al.  Environmental tobacco smoke exposure as determined by cotinine in black and white young adults: the CARDIA Study. Environ Res . 1993;;63:39-46.
9 +
Watts RR, Langone JJ, Knight GJ, Lewtas J.  Cotinine analytical workshop report: consideration of analytical methods for determining cotinine in human body fluids as a measure of passive exposure to tobacco smoke. Environ Health Perspect . 1990;;84:173-182.
10 +
Wall MA, Johnson J, Jacob P, Benowitz NL.  Cotinine in the serum, saliva and urine of nonsmokers, passive smokers and active smokers. Am J Public Health . 1988;;78:699-701.
11 +
Jarvis MJ, Russell MAH, Benowitz NL, Feyerabend C.  Elimination of cotinine from body fluids: implications for noninvasive measurement of tobacco smoke exposure. Am J Public Health . 1988;; 78:696-698.
12 +
Haley NJ, Axelrod CM, Tilton KA.  Validation of self-reported smoking behavior: biochemical analyses of cotinine and thiocyanate. Am J Public Health . 1988;;73:1204-1207.
13 +
Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Vesey C, Saloojee Y.  Biochemical markers of smoke absorption and self-reported exposure to passive smoking. J Epidemiol Community Health . 1984;; 38:335-339.
14 +
Etzel RA.  A review of the use of saliva cotinine as a marker of tobacco smoke exposure. Prev Med . 1990;;19:190-197.
15 +
Cummings SR, Richard RJ.  Optimum cutoff points for biochemical validation of smoking status. Am J Public Health . 1988;;78:574-575.
16 +
Woodward M, Tunstall-Pedoe H.  An iterative technique for identifying smoking deceivers with application to the Scottish Heart Health Study. Prev Med . 1992;;21:88-97.
17 +
Jarvis MJ, Tunstall-Pedoe H, Feyerabend C, Ve sey C, Saloojee Y.  Comparison of tests used to distinguish smokers from nonsmokers. Am J Public Health . 1987;;77:1435-1438.
18 +
Woodward M, Tunstall-Pedoe H, Smith WCS, Tavendale R.  Smoking characteristics and inhalation biochemistry in the Scottish population. J Clin Epidemiol . 1991;;44:1405-1410.
19 +
Tunstall-Pedoe H, Woodward M, Brown CA.  Tea drinking, passive smoking, smoking deception and serum cotinine in the Scottish Heart Health Study. J Clin Epidemiol . 1991;;44:1411-1414.
20 +
Emmons KM, Abrams DB, Marshall R, et al.  An evaluation of the relationship between self-report and biochemical measures of environmental tobacco smoke exposure. Prev Med . 1994;;23:35-39.
21 +
Cummings KM, Markello SJ, Mahoney M, et al.  Measurement of current exposure to environmental tobacco smoke. Arch Environ Health . 1990;;45: 74-79.
22 +
Patrick DL, Cheadle A, Thomson DC, et al.  The validity of self-reported smoking: a review and meta-analysis. Am J Public Health . 1994;;84:1086-1093.
23 +
Benowitz NL, Perez-Stable E, Herrera B, Jacob P.  African American—Caucasian differences in nicotine and cotinine metabolism. Clin Pharmacol Ther . 1995;;57:159.
24 +
Benowitz NL, Kuyt F, Jacob P, Jones RT, Osman AL.  Cotinine disposition and effects. Clin Pharmacol Ther . 1983;;34:604-611.
25 +
Langone JJ, Gjika HB, Van Vunakis H.  Nicotine and its metabolites: radioimmunoassays for nicotine and cotinine. Biochemistry . 1973;;12:5025-5030.
26 +
Greenberg RA, Haley NJ, Etzel RA, Loda FA.  Measuring the exposure of infants to tobacco smoke: nicotine and cotinine in urine and saliva. N Engl J Med . 1984;;310:1075-1078.
27 +
Matsukura S, Taminato T, Kitano N, et al.  Effects of environmental tobacco smoke on urinary cotinine excretion in nonsmokers: evidence for passive smoking. N Engl J Med . 1984;;311:828-832.
28 +
Wilcox RG, Hughes J, Roland J.  Verification of smoking history in patients after infarction using urinary nicotine and cotinine measurements. BMJ . 1979;;2:1026-1028.
29 +
Benowitz NL, Kuyt F, Jacob P, Jones RT, Osman AL.  Cotinine disposition and effects. Clin Pharmacol Ther . 1983;;34:604-611.
30 +
Castro A, Monji N.  Dietary nicotine and its significance in studies on tobacco smoking. Biochem Arch . 1986;;2:91-97.
31 +
Ezzati TM, Massey JT, Waksberg J, Chu A, Maurer KR.  Sample design: Third National Health and Nutrition Examination Survey. Vital Health Stat 2 . 1992;; No. (113) .
32 +
National Center for Health Statistics.  Plan and operation of the Third National Health and Nutrition Examination Survey, 1988-1994. Vital Health Stat . 1994;;1 ( (32) ).
33 +
Forthofer RN.  Investigation of nonresponse bias in NHANES II. Am J Epidemiol . 1983;;117: 507-515.
34 +
Flegal KM, Ezzati TM, Harris MI, et al.  Prevalence of diabetes and impaired glucose tolerance and plasma glucose levels in US population aged 20-74 yrs. Diabetes . 1987;;36:523-534.
35 +
Davis RA, Stiles MF, deBethizy JD, Reynolds JH.  Dietary nicotine: a source of urinary cotinine. Food Chem Toxicol . 1991;;29:821-827.
36 +
Domino EF, Hornback E, Demana T.  The nicotine content of common vegetables. N Engl J Med . 1993;;329:437.
37 +
Sheen SJ.  Detection of nicotine in foods and plant materials. J Food Sci . 1988;;53:1572-1573.
38 +
Bernert JT, Sosnoff C, Turner WE, et al.  Development of a rapid and sensitive method for serum cotinine analysis as a marker of exposure to environmental tobacco smoke. Clin Chem . 1994;;40: 1075.
39 +
Taylor JK. Quality Control of Chemical Measurements . Chelsea, Mich: Lewis Publishers; 1987;.
40 +
Long GL, Winefordner JD.  Limit of detection: a closer look at the IUPAC definition. Anal Chem . 1983;;55:712a-719a.
41 +
SAS Institute Inc. SAS Language: Reference, Version 6 . Cary, NC: SAS Institute Inc; 1990;.
42 +
Shah BV, Barnwell BG, Hunt PN, Lavange LM. SUDAAN User's Manual, Release 5.50 . Research Triangle Park, NC: Research Triangle Institute; 1991;.
43 +
Repace JL.  Won't mislead on passive smoking.... BMJ . 1994;;308:61.
44 +
Jarvis MJ.  Unless subjects eat 90 kg tomatoes a day. BMJ . 1994;;308:62.
45 +
Pattishall EN, Strope GL, Etzel RA, Helms RW, Haley NJ, Denny FW.  Serum cotinine as a measure of tobacco smoke exposure in children. AJDC . 1985;;139:1101-1104.
46 +
Overpeck MD, Moss AJ.  Children's exposure to environmental cigarette smoke before and after birth: health of our nation's children, United States, 1988.  In: Advance Data From Vital and Health Statistics . Hyattsville, Md: National Center for Health Statistics; 1991;:No. 202.
47 +
Hammond SK, Sorensen G, Youngstrom R, Ockene JK.  Occupational exposure to environmental tobacco smoke. JAMA . 1995;;274:956-960.
48 +
Hinds WC, First MW.  Concentrations of nicotine and tobacco smoke in public places. N Engl J Med . 1975;;292:844-845.
49 +
Muramatsu M, Umemura S, Okada T, Tomita H.  Estimation of personal exposure to tobacco smoke with a newly developed nicotine personal monitor. Environ Res . 1984;;35:218-227.
50 +
Jenkins PL, Phillips TJ, Mulberg EJ, Hui SP.  Activity patterns of Californians: use of and proximity to indoor pollutant sources. Atmos Environ . 1992;;26A:2141-2148.
51 +
Kabat GC, Wynder EL.  Lung cancer in nonsmokers. Cancer . 1984;;53:1214-1221.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Comment

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems