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Adults and children exposed to second-hand smoke (SHS, also known as environmental tobacco smoke) inhale many of the same toxic chemicals as smokers do. SHS can cause or contribute to respiratory disease in people who have never smoked (Flor et al., 2024). It is specifically associated with COPD and the exacerbation of asthma (Su et al., 2024; Flexeder et al., 2019) as well as nasal irritation, respiratory symptoms, middle ear disease, reduced lung function and sudden infant death syndrome (DHHS, 2014).
Over 3% of respiratory deaths in Europe are due to SHS. For some specific respiratory diseases, the proportion is higher: around 3.7% of COPD deaths and 4.3% of deaths from lower respiratory tract infections are due to SHS. People who already have a chronic respiratory condition or a respiratory infection are at especially high risk from the adverse effects of SHS and should be protected from even brief exposure. The burden of SHS on respiratory health is particularly relevant in children, for whom it can have serious, long-term consequences (Carreras et al., 2021). While we are still learning about the respiratory health effects of aerosols from e-cigarettes and vaping, initial research already suggests health hazards stemming from second-hand exposure (Oriakhi, 2020; Islam et al., 2022; Rodriguez et al., 2023). Emerging evidence is also raising concerns about the health impacts of ‘thirdhand smoke’: chemicals from tobacco smoking that remain embedded in soft surfaces such as curtains, bedding and carpets, or settles as dust-like particles on hard surfaces such as walls and floors, and in vehicles (Matt et al., 2023).
Trends in exposure to second-hand smoke in Europe and its impacts on health
European residents’ exposure to SHS and the associated burden of respiratory disease decreased between 1990 to 2021. However, on average, around 31% of the EU population is estimated to be exposed to SHS at home, at work, during leisure activities, in educational institutions or in public settings (Henderson et al., 2020). It is difficult to assess exposure to SHS across settings, age groups and countries. A study focused on adolescents aged 12-16 found a mixed picture in Europe, with exposure rising, falling or remaining unchanged depending on the country between 1999 to 2018 (Ma et al., 2021). Another study covering 12 EU countries found very different levels of SHS outdoors (including around hospitals and schools): the presence of second-hand smoke was higher in countries with a higher prevalence of smoking and with less comprehensive tobacco control policies (Henderson et al., 2021). Eurobarometer surveys on European residents’ attitudes towards tobacco and related products over the past few years found a deceleration in the indicators of reduction of smoking, including in public places.
SHS exposure can be significantly reduced by implementing total smoking bans in public places (Nogueira et al., 2022). A recent study in Germany (Burkhardt et al., 2023) credits smoking bans and regulations limiting SHS following European legislation with a decisive contribution to a significant decline in non-smokers’ exposure to SHS. The researchers measured an 82% decline in urinary cotinine (a biomarker related to exposure to tobacco smoke) in non-smokers from 1995 to 2019.
What the EU is doing about second-hand smoke
In parallel to adopting a body of regulations and action on tobacco control, advertising, promotion and sponsorship (EC, 2021), the Council of the European Union issued a recommendation in 2009 on smoke-free environments. The Commission continuously supports Member States’ efforts in implementing the WHO Framework Convention on Tobacco Control. An update of this outdated recommendation is in process but has still not been completed. In addition, several EU Member States have banned smoking in public places, mainly indoors but in some cases also in outdoor areas (Henderson et al., 2021). Despite these efforts, a combination of insufficient regulation and/or weak enforcement in several countries means that significant proportions of the population may still be exposed to SHS (Nogueira et al., 2022).