Children’s Environmental Health in Michigan

Neurotoxicity: Second Hand Smoke

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Smoking is the leading cause of death in the United States, taking an estimated 443,000 lives each year. Of these 443,000 deaths, 49,400 result from exposure to second-hand smoke (Mokdad et al., 2004). According to the U.S. Surgeon General (USDHHS, 2006) exposure to second-hand smoke (SHS) causes lung cancer, heart disease, and respiratory effects in nonsmokers, and increases the risk of Sudden Infant Death Syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma in children. Second-hand smoke is also a known neurotoxicant. Exposure to even low levels of SHS has been linked to cognitive impairments in children (Yolton, 2005). Exposures to secondhand smoke pre-conception, prenatally, and postnatally all have the potential to influence a child’s cognitive development (USDHHS, 2006). Exposure to tobacco smoke, particularly direct exposure in utero through maternal smoking, is associated with negative behavioral and cognitive effects in children. Almost 19% of Michigan high school students smoke. An estimated 716,000 kids are exposed to second-hand smoke in Michigan, and an estimated 18,400 Michigan high school students will start smoking every year. (CFTFK, 2007). In addition to health costs, smoking and its effects have a significant impact on health care costs and costs to the State. The American Lung Association estimates the smoking-related costs in Michigan are nearly $7.3 billion annually (ALA, 2009).

This chapter will summarize SHS exposure and associated health effects, present leading policy practices from other states and provide policy recommendations to minimize childhood second-hand smoke exposure in Michigan.

Contents

Michigan Highlights

Exposure Data

Smoking is the leading cause of death in the United States, taking an estimated 443,000 lives each year. Of these 443,000 deaths, 49,400 result from exposure to second-hand smoke (Mokdad et al., 2004). The American Lung Association (ALA) estimates that over 14,500 Michiganders die each year due to smoking, including 1,740 deaths due to SHS (ALA, 2009). The ALA estimates that smoking-related economic costs in Michigan are nearly $7.3 billion annually (ALA, 2009).

The annual rate of deaths that can be attributed to smoking in Michigan is 281.9 deaths per 100,000 people, much higher than the national rate of 247.8 deaths per 100,000 people (SAMMEC, 2004; ALA, 2009).[1] An estimated 298,000 kids under 18 in Michigan in 2007 will ultimately die prematurely from smoking (CFTFK, 2007).

Policy

To reduce health hazards posed to children by exposure to SHS, strongly consider adopting the following policies:

Background Information

Sources of Secondhand Smoke (SHS)

Second-hand smoke consists of both‚ “mainstream smoke,” the smoke exhaled from the person smoking and “sidestream smoke,” the smoke emitted from the burning end of a tobacco product (NCI, 2007). In the U.S., cigarettes are the predominant source of SHS, followed by pipes and cigars (NCI, 2007). Cigarette smoking releases a complex mixture of toxicants including nicotine, carbon monoxide, and cyanide (NCI 2007). Over 4,000 different compounds have been identified in tobacco smoke, and at least 250 of these chemicals are known to be toxic or carcinogenic (USDHHS, 2006). The composition of SHS is influenced by many factors including the type of tobacco, the extent of chemical additives to the tobacco, the type of paper used to wrap the tobacco, and the way the tobacco is smoked (NCI, 2007).

Neurotoxicity and Secondhand Smoke

Second-hand smoke exposure both during pregnancy and childhood may affect cognitive development in children (USDHHS, 2006, NIH 2010). As with other environmental exposures, this association is highly complex and can be influenced by many confounding factors including social class, parental education, and the extent of developmentally-stimulating characteristics of the home environment (USDHHS, 2006). Furthermore, challenges remain in separating out prenatal and postnatal exposures when evaluating health effects (USDHHS, 2006). For these reasons, further research is necessary to better understand the association between SHS and neurological effects (USDHHS, 2006).


Despite the difficulties in evaluating the neurotoxic effects of SHS, studies strongly point towards a relationship between childhood exposure to secondhand smoke and negative behavior and cognitive effects in children; this relationship is particularly true for in utero exposure for maternal smoking during pregnancy (DiFranza et al., 2004).

Exposure of pregnant women to SHS has been shown to place the exposed child at increased risk for impaired speech, impaired language skills, intelligence deficits, learning disorders, and attention deficits (DiFranza et al., 2004, Garcia et al., 2007). It is believed that these effects are the result of fetal hypoxia resulting from either nicotine or carbon monoxide in the mother’s system; it is also possible that nicotine alters cell proliferation and differentiation in specific neurotransmitter receptors in the developing brain of the fetus (Eskenazi & Castorina, 1999).

The relationship between postnatal SHS exposure and neurodevelopmental and behavioral problems is less clear, although several studies do report positive associations (Eskenazi & Castorina, 1999, Best, 2009). In one study, the relationship between SHS, as measured by serum cotinine levels, and cognitive ability was assessed for children age 6-16 years who were enrolled in the Third National Health and Nutrition Examination Survey (NHANES III) (Yolton et al., 2005). This study reported a significant association between serum cotinine concentration and decreased reading scores, math scores, and visual-spatial skills (Yolton et al., 2005). Furthermore, effects of SHS were observed at even the lowest levels of exposure. Specifically, a dose-response relationship between decreasing mean test scores and cotinine levels of 0.1-1 ng/ml, 1-3 ng/ml, and 3-15 ng/ml was observed (Yolton et al., 2005). In other studies, parental smoking has been linked to lower test scores for their children and an increased likelihood for their children to repeat kindergarten or first grade (DiFranza et al., 2004).

It is clear from the literature that exposure to tobacco smoke, particularly direct exposure in utero, is associated with negative behavioral and cognitive effects in children. While the extent of this relationship with SHS needs to be clarified through additional well-designed epidemiological studies, the evidence suggests that immediate action should be taken to implement policies that will help reduce childhood exposure to tobacco smoke.

Childhood Exposure to Secondhand Smoke

Children are exposed to SHS when anyone around them is smoking. The developing fetus can also be exposed through the placenta to SHS, even if the mother is not a smoker herself (Eskenazi, 1999). Homes and workplaces are the predominant locations for exposure to SHS (USDHHS, 2006). Therefore, children are most likely exposed to SHS in the home environment, but exposure may also occur in other microenvironments where smoking is prevalent, such as cars.[3] The level of exposure to SHS is a function of the intensity of smoking in a microenvironment and the dilution of that smoke by ventilation or other factors that may remove smoke from the air (USDHHS, 2006). However, even if dilution mechanisms are in place, the U.S. Surgeon General has concluded that there is no risk-free level of exposure to second-hand smoke. Eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from exposure to second-hand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings, does not entirely eliminate exposures of nonsmokers to second-hand smoke (USDHHS, 2006).

Global and Nationwide Exposure Data

While overall exposures to SHS have reportedly decreased since results published in 1986, children’s exposure to SHS in the U.S. remains of particular concern. It is estimated that 60% of children in the United States between the ages of 3 and 11 are exposed to second-hand smoke (USDHHS, 2006). Children between the ages of 3 and 11who live with adult smokers, have almost twice the amount of serum cotinine, a biomarker of exposure to second-hand smoke, than non-smoking adults (USDHHS, 2006). Serum cotinine concentrations in children are listed in Figure 1. The table shows that on average, younger children (age 3-11 years) have higher exposure to SHS, as measured by serum cotinine concentrations. Metabolism differences, proximity to parents, and differences in time spent in the home may account for the higher levels observed in younger children (Ahijevych, 2006),.

Figure 1: Serum cotinine concentrations (ng/ml) for U.S. children1(nonsmokers) age 3-19 years2.

Serum cotinine concentrations (ng/ml) for U.S. children (nonsmokers) age 3-19 years.
Serum cotinine concentrations (ng/ml) for U.S. children1 (nonsmokers) age 3-19 years2.

1Participants in NHANES 1999-2002.

2Table reconstructed from source: U.S. Department of Health and Human Services 2006.

Michigan Exposure Data

Children’s exposure to second-hand smoke is strongly dependent on the degree to which people around them smoke. Michigan has above average smoking rates compared to the rest of the nation. As of 2006, the proportion of Michigan adults who were smokers had exceeded the U.S. median for each of the past ten years (Campaign for Tobacco-Free Kids (CFTFK), 2007). Figure 2 shows the overall rates of cigarette smoking in Michigan compared to the national average. While smoking rates are declining both within the state and across the country, the percent of people in Michigan who smoke is consistently above the national average.

Figure 2: The proportion of adults who smoke cigarettes in Michigan versus the United States as a whole, 1998-2007 (Fussman, 2008).

The proportion of adults who smoke cigarettes in Michigan versus the United States as a whole, 1998-2007 (Fussman, 2008).
The proportion of adults who smoke cigarettes in Michigan versus the United States as a whole, 1998-2007 (Fussman, 2008).


In 2008, an estimated 21.1% of Michigan adults were current smokers. In 2009, the current national adult smoking rate was 19.8% (ALA, 2009).

In Michigan, 46.3% (42.7-50.0) of adult smokers had at least one child living in their household (Garcia et al., 2007). As a result, approximately 716,000 Michigan children are exposed to second-hand smoke in their own households (CFTFK, 2007). In 2007, 14.1% of births were to mothers who smoked during their pregnancy (Kids Count, 2007).


In Michigan, 18.0% of high school students smoke (below the national average of 20.0%) and 7.2% of middle school students smoke (above the national average of 6.3%) (ALA, 2009). According to the Campaign for Tobacco-Free Kids, 21,200 kids (under 18) in Michigan become new daily smokers each year. Each year, kids in the state buy or smoke 20.4 million packs of cigarettes (CFTFK, 2007).

Policy Summary and Analysis

Smoking Bans

Michigan Policy Highlights
  1. By statute, smoking is banned in child care institutions and health care facilities (MCL § 333.12604 & § 333.12604a).
  2. On December 18, 2009, Michigan became the 38th state to pass a general smoking ban, which takes effect May 1, 2010: “An individual shall not smoke in a public place or at a meeting of a public body, and a state or local governmental agency or the person who owns, operates, manages, or is in control of a public place shall make a reasonable effort to prohibit individuals from smoking in a public place.”

(MCL 333.12603)

Exemptions: Cigar bars, tobacco specialty retail stores, casino gaming areas. However, casino bars and restaurants are not exempt. Employers must make a “reasonable effort” to prohibit individuals from smoking in their place of employment.

Employers (the owner, operator, manager, or person having control of a public place, a food service establishment, or a casino shall do all of the following:1. Post a “no-smoking” sign or the “no smoking” symbol at each entrance to and in every building; 2. Remove all ashtrays and smoking paraphernalia; 3. Inform individuals who are smoking that they are violating the law and subject to penalties; 4. Refuse to serve an individual smoking in violation of the law; 5. Ask an individual smoking in violation of the law to stop, and, if the individual refuses, ask that individual to leave the premises. (MCLA 333.12603(2))

Analysis and Policy Highlights from Other States

Unlike Michigan, 27 states [4]as well as Washington DC and Puerto Rico have enacted 100% smoke-free gaming laws banning smoking in all casinos.

Vermont does not exempt tobacco reality shops from their statewide smoking ban.

Evaluation and Recommendations

Michigan should continue to improve the statewide smoking ban by expanding the ban to require casinos to be 100% smoke-free. Additionally, the state’s smoking ban should include tobacco reality shops.

Smoking Prevention

Tobacco-free policies can make an impact on youth smoking by changing the social norm of tobacco use by demonstrating that most people do not smoke. Smoke-free work site laws, 24/7 tobacco-free school policies and smoke-free college campus policies have been proven to prevent youth smoking and encourage youth smokers to quit (CFTFK, 2006). Strictly enforcing laws prohibiting illegal tobacco sales to minors can also reduce youth smoking (CFTFK, 2008).

Michigan Policy Highlights
  1. Michigan does not allow vending machines that dispense cigarettes, cigars, or other tobacco products to be in public areas that are legally accessible to minors, unless said vending machines are located in work areas restricted to the public or are in establishments with class C liquor licenses (Michigan Penal Code Act 328 § 750.470).
  2. Michigan requires that purchasers of cigarettes be 18 or older but has no requirement that ID be presented (ALA, 2009).
  3. Michigan’s FY 2011 budget includes $5.7 million for Tobacco Control Program Funding.
  4. Michigan has a $2.00 cigarette tax (Michigan Department of Treasury, 2007).
  5. Michigan’s tax on Other Tobacco Products is 32% of the wholesale price, which is a significantly lower percentage than the state cigarette tax.


Analysis and Policy Highlights from Other States
  1. Michigan has among the least restrictive tobacco smoke prevention laws of any state. The American Lung Association’s State of Tobacco Control 2008 report gave Michigan a grade of “F” in tobacco prevention and control spending, and an “F” in cessation coverage. However, Michigan’s cigarette tax earned a grade of "C" ($2.00 per pack of 20) (ALA 2010).
  2. Many other states have met the CDC Best Practice estimate for tobacco control spending in their state. Michigan’s FY 2011 budget includes $5.7 million for Tobacco Control Program Funding, which includes $3.1 million in federal funding from the Centers for Disease Control and Prevention and $2.6 million in state funding from the Healthy Michigan Fund. However, the CDC’s report on Best Practices for Comprehensive Tobacco Control Programs recommends that Michigan spend $121.2 million annually (CDC 2007).
  3. Many other states have extensive policies to prevent youth access to cigarettes. For example:
    1. Maine goes farther than Michigan by imposing measures such as: requirements for placement of cigarettes in stores and sign requirements for vending machine sales (1,2, ME Rev Stat. ANN. tit. 22, § 1555-B (11); ME Rev. Stat. ANN. tit. 22, § 1553-A).
    2. Vermont imposes a license suspension for sale to minors (Sec. 13, VT ACT 58).
    3. Texas has a minimum distance requirement for the placement of cigarette advertisements near schools and churches, and also requires photo ID for all persons under age 27 (Tex. Health & Safety Code §§ 161.121 to 161.125; Tex. Health & Safety Code ANN. § 161.083).

The Family Smoking Prevention and Tobacco Control Act (FSPTC), signed into law on June 22, 2009 by President Obama, grants the U.S. FDA the authority to regulate tobacco products and their marketing. The FDA will have the authority to restrict the tobacco industry’s marketing to children, ban the use of flavoring in tobacco products, ban misleading descriptive terms (such as “high” or “low”), require larger more effective warning labels, require disclosure of all ingredients, additives, and smoke constituents, and require changes to make tobacco products less harmful (ACS CAN).

There are several key dates for federal action that explicitly address smoking prevention and tobacco control in relation to children’s health:

  1. Restrictions to marketing to youth[5]: June 22, 2010
  2. FDA published action plan for enforcement of the restrictions of marketing to youth: By October 2010
  3. FDA shall report to Congress on the implications of raising the minimum tobacco purchasing age: By April 2015
Evaluation and Recommendations

Michigan is ranked 10th with 5 other states in terms of its state cigarette tax of $2.00 (Campaign For Tobacco-Free Kids, 2009). Michigan should increase the tax on other tobacco products to parity with the cigarette tax, and allocate a portion of the generated revenue to fund tobacco prevention programming. Tobacco tax increases reduce tobacco use among adults and youth, save lives and reduce health care costs.

Michigan should pursue measures to prevent youth access to cigarettes such as restrictions on: placement of cigarettes in stores, vending machine sales, license suspension for sale to minors, minimum distance for the placement of cigarette advertisements near schools and churches. Michigan should also more strongly enforce the law-prohibiting sale of tobacco to minors and require an ID for the purchase of cigarettes. The recent passage of the FDA Family Smoking Prevention and Tobacco Control Act (FSPTCA) will result in additional recommendations and activities to reduce youth access to tobacco. Michigan should be aware of key federal action dates not only for enforcement purposes, but also as an opportunity to promote comprehensive tobacco control programs and policies in the state.

Michigan should enhance tobacco prevention and control spending by allocating adequate funding to meet or exceed the CDC Best Practices range.

Summary of Policy Recommendations for Eliminating Exposure to SHS and Decreasing Youth Access to Tobacco in Michigan

To reduce health hazards posed to children by exposure to SHS, strongly consider adopting the following policies:

  1. Michigan should require that cigarette purchasers present ID as in other model states.
  2. Michigan should increase the funding allocated for Tobacco Control to the CDC recommended level of $121 Million.
  3. Michigan should increase the tax on other tobacco products to parity with the cigarette tax.
  4. Michigan should implement requirements for placement of cigarettes and vending machines, and adopt requirements for vending machine signage, in stores. The FDA’s FSPTCA will restrict self-service displays and vending machines to adult-only establishments.
  5. A provision to suspend retail licenses for stores that sell tobacco products to minors should be included in any retailer licensing legislation.
  6. Michigan should establish a minimum distance for the placement of cigarette advertisements near schools and churches. (This may be addressed by the FDA FSPTCA[6]).

References

Ahijevych, K. (2006, May 19). Nicotine metabolism variability and nicotine addiction. Addicted to Nicotine: A National Research Forum. Retrieved August 28, 2009, from http://www.nida.nih.gov/Meetsum/Nicotine/Ahijevych.html

American Cancer Society Cancer Action Network (ACS CAN). 2010. www.acscan.org/content/category/tobacco/

American Lung Association (ALA). 2008. What is the connection between tobacco and lung disease? Accessed January 15, 2009, at: http://www.lungusa.org/site/c.dvLUK9O0E/b.4103549/k.9856/Tobacco_Use.htm#tobacco2

American Lung Association (ALA). 2010. State of Tobacco Control 2010. http://www.stateoftobaccocontrol.org/state-grades/michigan/

American nonsmokers rights foundation (ANRF). 2011. www.smokefreecasinos.org

Best, D. 2009. Technical Report- Secondhand and Prenatal Tobacco Smoke Exposure. American Academy of Pediatrics. doi:10.1542/peds.2009-2120.

Campaign for Tobacco-Free Kids. (2006, July 27). Smoke-free laws encourage smokers to

quit and discourage youth from starting (Fact sheet). Retrieved August 28, 2009, from

http://www.tobaccofreekids.org/research/factsheets/pdf/0198.pdf

Campaign for Tobacco-Free Kids. “The Toll of Tobacco in Michigan.” 2007.http://www.tobaccofreekids.org/reports/settlements/toll.php?StateID=MI.

Campaign for Tobacco-Free Kids (2008, July 14). Enforcing laws prohibiting cigarette sales to kids reduces youth smoking. Retrieved August 28, 2009, from http://www.tobaccofreekids.org/research/factsheets/pdf/0049.pdf

Center for Disease Control and Prevention (CDC). 2007. Best Practices for Comprehensive Tobacco Control Programs. http://www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/

DiFranza JR, Aligne CA, Weitzman M. 2004. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 113: 1007-1015.

Eskenazi B., & Castorina R. 1999. Association of Prenatal Maternal or Postnatal Child Environmental Tobacco Smoke Exposure and Neurodevelopmental and Behavioral Problems in Children. Environmental Health Perspectives 107: 991-1000.

Fussman C, Lyon-Callo SK, and Rafferty AP. 2008. Health Risk Behaviors in the State of Michigan: 2007 Behavioral Risk Factor Survey. Lansing, MI: Michigan Department of Community Health, Bureau of Epidemiology, Chronic Disease Epidemiology Section. http://www.michigan.gov/documents/mdch/80163_MSU_PS-BRFS_text_FINAL_259176_7.pdf.

Garcia EM, Lyon-Callo SK, Rafferty AP. 2007. Health Risk Behaviors in the State of Michigan: 2006 Behavioral Risk Factor Survey. Lansing, MI: Michigan Department of Community Health, Bureau of Epidemiology, Chronic Disease Epidemiology Section. http://www.michigan.gov/documents/mdch/75634_MSU_PS-BRFS_2006AnnualReport_FINAL_216699_7.pdf.

Greater Boston Physicians for Social Responsibility (GBPSR). In Harm’s Way: Toxic Threats to Child Development. May 2000.

Kids Count Data Center. 2009. Annie E. Casey Foundation. http://datacenter.kidscount.org/data/bystate/StateLanding.aspx?state=MI.

Lexis Nexis. Legislative Database.

Michigan Department of Treasury. 2007. Tobacco Tax Information. http://www.michigan.gov/taxes/0,1607,7-238-43542_43547---,00.html.

Mokdad AH, Marks JS, Stroup DF, et al. 2004. Actual Causes of Death in the United States, 2000. Journal of the American Medical Association 291(10):1238-1245.

National Cancer Institute (NCI). 2007. Second Hand Smoke: Questions and Answers. Reviewed 8/1/07; accessed 11/15/08 at: http://www.cancer.gov/cancertopics/factsheet/Tobacco/ETS.

National Conference of State Legislators (NCSL). Environmental Health Database. http://www.ncsl.org/programs/environ/envhealth/toxics.htm.

National Institute on Drug Database (NIH) .2010. Smoking and Pregnancy- What are the Risks? Accessed 12/14/10 at: http://drugabuse.gov/researchreports/nicotine/useRisks.html#maternal.

Smoking-Atrributable Mortality, Morbidity, and Economic Costs (SAMMEC). 2004. Accessed January 15, 2009, at: https://apps.nccd.cdc.gov/sammec/index.asp.

Statehealthfacts.org. 2008. Public Place Smoking Bans. Henry J. Kaiser Family Foundation. Accessed July 22, 2009, at: http://www.statehealthfacts.org/comparetable.jsp?ind=86&cat=2

United States Department of Health and Human Services (HHS). 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006) Weil, William. Email to Genevieve Howe. September 13, 2007.

Yolton K, Dietrich K, Auinger P, Lanphear BP, Hornung R. 2005. Exposure to environmental tobacco smoke and cognitive abilities among U.S. children and adolescents. Environmental Health Perspectives 113: 98-103.


  1. Note: Smoking-attributable death rates are calculated for adults aged 35 years and older and do not include burn or second hand smoke deaths.
  2. Implementation of the ban on outdoor tobacco advertising within 1,000 feet of schools and playgrounds and limitations on advertising in publications with significant teen readership and outdoor and point-of-sale advertising is currently the subject of pending litigation
  3. The term “microenvironment” refers to smaller indoor environments where the concentration of pollutants is fairly evenly distributed throughout the space (USDHHS, 2006).
  4. www.smokefreecasinos.org
  5. Restrictions can include: banning all remaining tobacco brand sponsorships of sports and entertainment events, and banning free giveaways of non-tobacco items with the purchase of a tobacco product or in exchange for coupons or proofs of purchase.
  6. Implementation of the ban on outdoor tobacco advertising within 1,000 feet of schools and playgrounds and limitations on advertising in publications with significant teen readership and outdoor and point-of-sale advertising is currently the subject of pending litigation
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