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Introduction: Despite knowledge about major health effects of secondhand tobacco smoke (SHS) exposure, systematic incorporation of SHS screening and counseling in clinical settings has not occurred.

Methods: A three-round modified Delphi Panel of tobacco control experts was convened to build consensus on the screening questions that should be asked and identify opportunities and barriers to SHS exposure screening and counseling. The panel considered four questions: (1) what questions should be asked about SHS exposure; (2) what are the top priorities to advance the goal of ensuring that these questions are asked; (3) what are the barriers to achieving these goals; and (4) how might these barriers be overcome. Each panel member submitted answers to the questions. Responses were summarized and successive rounds were reviewed by panel members for consolidation and prioritization.

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Results: Panelists agreed that both adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from any tobacco products in their usual environment. The panel found that consistent clinician training, quality measurement or other accountability, and policy and electronic health records interventions were needed to successfully implement consistent screening.

Conclusions: The panel successfully generated screening questions and identified priorities to improve SHS exposure screening. Policy interventions and stakeholder engagement are needed to overcome barriers to implementing effective SHS screening.

Implications: In a modified Delphi panel, tobacco control and clinical prevention experts agreed that all adults and children should be screened during clinical encounters by asking if they are exposed or have ever been exposed to smoke from tobacco products. Consistent training, accountability, and policy and electronic health records interventions are needed to implement consistent screening. Increasing SHS screening will have a significant impact on public health and costs.

The FDA has not found any e-cigarettes to be safe or effective in helping smokers quit. The 2016 Surgeon General's Report states that e-cigarettes can expose people to several chemicals known to have adverse health effects. Based on this, the American Lung Association does not support the use of e-cigarettes. Instead, we encourage you to talk to your healthcare provider about using one of the seven FDA-approved medications that have been proven to help smokers quit.

Prior to the Delphi meeting, a four-member planning committee developed discussion questions based on a review of the literature and input from other panel members. Meeting presentations explored existing evidence and ongoing efforts to improve electronic health record (EHR) documentation and clinical screening for SHS exposure in children and adults, and introduced the modified Delphi methods planned for the study. Our committee proposed three or four rounds, depending on whether the group reached satisfactory consensus.

In Round 1, panel members were asked to write individual responses to the four questions: (1) What is (are) the appropriate and/or standardized screening question(s)?; (2) What are the top priorities to advance the goal of asking the right questions about SHS exposure?; (3) What are the main barriers to succeeding in achieving those priorities (scientific evidence, social strategies, political will)?; and (4) How should those barriers be approached (who, what actions)? The answers to the questions were transcribed, summarized and sent to panel members for priority ranking.

However, finding ways to implement the increased surveillance is not simple. Multiple recommendations as well as barriers to implementation were identified. Although overcoming the barriers that prevent physicians from asking these questions has been a long-term goal, the consensus of the Delphi panel was that substantial work remains to be done.

Although screening for tobacco use has increased in recent years,16 many tobacco control efforts focus primarily on smoking cessation, or treatment of tobacco addiction, and not on elimination of SHS exposure, even though some smokers are more motivated by the impact of SHS exposure on their loved ones than the effects of tobacco on their own health.17 One way to overcome this barrier is to train clinicians so that SHS screening becomes routine. But fewer than half of medical students report having the skills to counsel patients about SHS exposure and only 12% report observing faculty members discuss SHS exposure with patients.18 SHS exposure training should begin in medical and other health professions schools and must continue through post-graduate training for all disciplines and specialties.

In addition to increased training for individual clinicians, practice-level systems change can have a large impact on SHS exposure screening and counseling. The Clinical Effort Against Smoking Exposure intervention has increased physician counseling about SHS, and increased identification of families who have rules regarding smoking in the home and car, places where SHS exposure is likely to occur.19 The Kids Safe and Smokefree Multilevel Intervention to Reduce Child Tobacco Smoke Exposure has also shown positive results.20 Similar content might be expanded to adult medicine practices, to increase the impact of individual SHS exposure interventions for all family members. Nursing and other clinical staff may also be underutilized in the effort to increase SHS exposure screening. Research has shown that just under half of pediatric nurses routinely ask about smoking in the home during inpatient encounters.21 However, when screening questions were added to nurse intake forms, the majority of inpatient adult and pediatric patients were screened.22

Assessing pediatric and adult patients for SHS exposure is both important and feasible. However, additional research is needed to testing the proposed screening questions in diverse populations and various adult and pediatric primary care settings. In addition, dissemination and implementation studies are needed to assess ways in which implementation of these recommendations might best impact practice change and individual behavior change to best protect vulnerable children and adults from SHS exposure.

Smoking status recodes were first added to the public use data files in 1970. From 1970 through 1980, the data files contained only the recodes and not the original variables. Beginning in 1983, the next year in which smoking questions were asked, both the original smoking variables and their recodes were included on the data files.

[1983 is the first year for which the answer to the screening question (ever smoked 100 cigarettes) was reported. In the previous years, only the recode was put on the public use file, not the responses to the individual component questions.]

Elevated pollution from other sources such as high ozone in the summer and pollution from living near traffic or other industrial sources will compound the effects of smoke exposure. People living near high traffic and other sources are often in low income communities of color and are known to be more sensitive to the impacts of pollution, including particulate matter pollution, which can be exacerbated by wildfires.

Individual local air districts implement and enforce local rules and regulations, including the issuance of burn permits to local land managers for prescribed fire on the landscape. Following initial permitting, the local air district provides final burn authorization based on forecasted local meteorology and air quality before the prescribed burn can commence. Local air districts also work independently and in partnership with CARB to monitor the smoke emissions and air quality impacts from prescribed fire.

Major settings of exposure to secondhand smoke include workplaces, public places such as bars, restaurants and recreational settings, and homes (4). Workplaces and homes are especially important sources of exposure because of the length of time people spend in these settings. The home is a particularly important source of exposure for infants and young children. Children and nonsmoking adults can also be exposed to secondhand smoke in vehicles, where levels of exposure can be high. Exposure levels can also be high in enclosed public places where smoking is allowed, such as restaurants, bars, and casinos, resulting in substantial exposures for both workers and patrons (3).

Secondhand smoke exposure can be measured by testing indoor air for respirable (breathable) suspended particles (particles small enough to reach the lower airways of the human lung) or individual chemicals such as nicotine or other harmful and potentially harmful constituents of tobacco smoke (3, 5).

Yes. The U.S. Environmental Protection Agency, the U.S. National Toxicology Program, the U.S. Surgeon General, and the International Agency for Research on Cancer have all classified secondhand smoke as a known human carcinogen (a cancer-causing agent) (1, 3, 7, 9). In addition, the National Institute for Occupational Safety and Health (NIOSH) has concluded that secondhand smoke is an occupational carcinogen (3).

Some research also suggests that secondhand smoke may increase the risk of breast cancer, nasal sinus cavity cancer, and nasopharyngeal cancer in adults (10) and the risk of leukemia, lymphoma, and brain tumors in children (3). Additional research is needed to determine whether a link exists between secondhand smoke exposure and these cancers.

Secondhand smoke exposure during pregnancy has been found to cause reduced fertility, pregnancy complications, and poor birth outcomes, including impaired lung development, low birth weight, and preterm delivery (11).

The only way to fully protect nonsmokers from secondhand smoke is to eliminate smoking in indoor workplaces and public places and by creating smokefree policies for personal spaces, including multiunit residential housing. Opening windows, using fans and ventilation systems, and restricting smoking to certain rooms in the home or to certain times of the day does not eliminate exposure to secondhand smoke (3, 4). e24fc04721