Environmental tobacco smoke exposure (ETSE) was race/ethnicity-specific, but how the race/ethnicity-specific ETSE has changed over time, diverging or converging, remains unclear. We examined ETSE trends by race/ethnicity in US children aged 3–11 years.
We analyzed the data of 9678 children who participated in the biennial National Health and Nutrition Examination Surveys, 1999–2018. ETSE was defined as serum cotinine ≥ 0.05 ng/ml, with ≥ 1 ng/ml as heavy exposure. For trend description, adjusted biennial prevalence ratios (abiPR: the ratio associated with a 2-year increase in time) were estimated by race/ethnicity. The prevalence ratios between races/ethnicities were used to quantify ethnoracial differences in different survey periods. Analyses were performed in 2021.
The overall ETSE prevalence was cut by almost half, from 61.59% (95% confidence interval = 56.55%, 66.62%) in the 1999–2004 survey to 37.61% (33.90%, 41.31%) in 2013–2018, exceeding the national 2020 health target (47.0%). However, the decrease occurred unequally between races/ethnicities. Heavy ETSE declined significantly in white [abiPR = 0.80 (0.74, 0.86)] and Hispanic children [0.83 (0.74, 0.93)], but insignificantly in black children [0.97 (0.92, 1.03)]. Consequently, the adjusted prevalence ratio between black children and white children increased from 0.82 (0.47, 1.44) in 1999–2004 to 2.73 (1.51, 4.92) in 2013–2018 for heavy ETSE. Hispanic children remained at the lowest risk throughout the study period.
Overall ETSE prevalence was cut by half between 1999 and 2018. However, due to uneven declines, the gaps between black children and others have expanded in heavy ETSE. Special vigilance is needed in preventive medicine practice with black children.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
The deidentified participant's data used for this study are publicly available NHANES data from the National Center for Health Statistics, Centers for Disease Control and Prevention, United States at https://wwwn.cdc.gov/nchs/nhanes/Default.aspx.
David A, Esson K, Perucic A-M, Fitzpatrick C. Tobacco use: equity and social determinants. In: Blas E, Sivasankara Kurup A, editors. Equity, social determinants and public health programmes. Geneva: World Health Organization; 2010. p. 199–218.
Kann L, McManus T, Harris WA, Shanklin SL, Flint KH, Queen B, Lowry R, Chyen D, Whittle L, Thornton J, et al. Youth risk behavior surveillance - United States, 2017. MMWR Surveill Summ. 2018;67(8):1–114.
Merianos AL, Jandarov RA, Choi K, Mahabee-Gittens EM. Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999–2014. Prev Med. 2019;123:138–42.
Tsai J, Homa DM, Gentzke AS, Mahoney M, Sharapova SR, Sosnoff CS, Caron KT, Wang L, Melstrom PC, Trivers KF. Exposure to secondhand smoke among nonsmokers - United States, 1988–2014. MMWR Morb Mortal Wkly Rep. 2018;67(48):1342–6.
Zhang X, Johnson N, Carrillo G, Xu X. Decreasing trend in passive tobacco smoke exposure and association with asthma in U.S. children. Environ Res. 2018;166:35–41.
Chen CI, Burton T, Baker CL, Mastey V, Mannino D. Recent trends in exposure to secondhand smoke in the United States population. BMC Public Health. 2010;10:359.
Pirkle JL, Bernert JT, Caudill SP, Sosnoff CS, Pechacek TF. Trends in the exposure of nonsmokers in the U.S. population to secondhand smoke: 1988–2002. Environ Health Perspect. 2006;114(6):853–8.
McIntire RK, Macy JT, Seo DC, Nelson AA, Kolbe LJ. Secondhand smoke exposure in cars and rooms: trend comparisons among subpopulations of nonsmoking U.S. middle and high school students. Nicotine Tob Res. 2014;16(6):663–71.
Nardone N, Jain S, Addo N, St Helen G, Jacob P 3rd, Benowitz NL. Sources and biomarkers of secondhand tobacco smoke exposure in urban adolescents. Acad Pediatr. 2020;20(4):493–500.
Sangmo L, Liu B, Elaiho C, Boguski L, Yaker M, Resnick M, Malbari A, Wilson KM. Reported marijuana and tobacco smoke incursions among families living in multiunit housing in New York City. Acad Pediatr. 2021;21(4):670–6.
Shenassa ED, Rossen LM, Cohen J, Morello-Frosch R, Payne-Sturges DC. Income inequality and US children’s secondhand smoke exposure: distinct associations by race-ethnicity. Nicotine Tob Res. 2017;19(11):1292–9.
The Lancet Respiratory M. COVID-19, smoking, and cancer: a dangerous liaison. Lancet Respir Med. 2021;9(9):937.
Klein JD, Resnick EA, Chamberlin ME, Kress EA: Second-hand smoke surveillance and COVID-19: a missed opportunity. Tob Control 2021.
Martin B, DeWitt PE, Russell S, Anand A, Bradwell KR, Bremer C, Gabriel D, Girvin AT, Hajagos JG, McMurry JA, et al. Characteristics, outcomes, and severity risk factors associated with SARS-CoV-2 infection among children in the US National COVID Cohort Collaborative. JAMA Netw Open. 2022;5(2):e2143151.
Fernandes DM, Oliveira CR, Guerguis S, Eisenberg R, Choi J, Kim M, Abdelhemid A, Agha R, Agarwal S, Aschner JL, et al. Severe acute respiratory syndrome coronavirus 2 clinical syndromes and predictors of disease severity in hospitalized children and youth. J Pediatr. 2021;230:23-31.e10.
Götzinger F, Santiago-García B, Noguera-Julián A, Lanaspa M, Lancella L, Calò Carducci FI, Gabrovska N, Velizarova S, Prunk P, Osterman V, et al. COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health. 2020;4(9):653–61.
Leventer-Roberts M, Grinshpun A, Kohn E, Andra SS, Arora M, Berkovitch M, Kozer E, Landrigan P, Levine H. Environmental tobacco smoke exposure among children by urinary biomarkers and parent report. Acad Pediatr. 2021;21(4):663–9.
Farber HJ, Walley SC, Groner JA, Nelson KE. Section on Tobacco C: Clinical practice policy to protect children from tobacco, nicotine, and tobacco smoke. Pediatrics. 2015;136(5):1008–17.
Altman DG, Royston P. The cost of dichotomising continuous variables. BMJ. 2006;332(7549):1080.
Wilson SE, Kahn RS, Khoury J, Lanphear BP. Racial differences in exposure to environmental tobacco smoke among children. Environ Health Perspect. 2005;113(3):362–7.
Benowitz NL, Perez-Stable EJ, Fong I, Modin G, Herrera B, Jacob P 3rd. Ethnic differences in N-glucuronidation of nicotine and cotinine. J Pharmacol Exp Ther. 1999;291(3):1196–203.
Jain RB. Trends in exposure to second hand smoke at home among children and nonsmoker adolescents. Sci Total Environ. 2016;542(Pt A):144–52.
Marano C, Schober SE, Brody DJ, Zhang C. Secondhand tobacco smoke exposure among children and adolescents: United States, 2003–2006. Pediatrics. 2009;124(5):1299–305.
Johnson CL, Paulose-Ram R, Ogden CL, Carroll MD, Kruszon-Moran D, Dohrmann SM, Curtin LR. National Health and Nutrition Examination Survey: analytic guidelines, 1999–2010. Vital Health Stat 2. 2013;3(161):1–24.
Curtin LR, Mohadjer LK, Dohrmann SM, Montaquila JM, Kruszan-Moran D, Mirel LB, Carroll MD, Hirsch R, Schober S, Johnson CL. The National Health and Nutrition Examination Survey: sample design, 1999–2006. Vital Health Stat 2. 2012;155:1–39.
Healthy People 2020 [https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives].
Hukkanen J, Jacob P 3rd, Benowitz NL. Metabolism and disposition kinetics of nicotine. Pharmacol Rev. 2005;57(1):79–115.
Ra CK, Pehlivan N, Kim H, Sussman S, Unger JB, Businelle MS. Smoking prevalence among Asian Americans: associations with education, acculturation, and gender. Prev Med Rep. 2022;30:102035.
Tillett T. Thirdhand smoke in review: research needs and recommendations. Environ Health Perspect. 2011;119(9):a399.
Matt GE, Quintana PJ, Destaillats H, Gundel LA, Sleiman M, Singer BC, Jacob P, Benowitz N, Winickoff JP, Rehan V, et al. Thirdhand tobacco smoke: emerging evidence and arguments for a multidisciplinary research agenda. Environ Health Perspect. 2011;119(9):1218–26.
Winickoff JP, Friebely J, Tanski SE, Sherrod C, Matt GE, Hovell MF, McMillen RC. Beliefs about the health effects of “thirdhand” smoke and home smoking bans. Pediatrics. 2009;123(1):e74-79.
Protano C, Vitali M. The new danger of thirdhand smoke: why passive smoking does not stop at secondhand smoke. Environ Health Perspect. 2011;119(10):A422.
Benowitz NL, Jacob P 3rd. Metabolism of nicotine to cotinine studied by a dual stable isotope method. Clin Pharmacol Ther. 1994;56(5):483–93.
National Health and Nutrition Examination Survey - questionnaires, datasets, and related documentation. In.: National Center for Health Statistics, Centers for Disease Control and Prevention; 2009.
Homa DM, Neff LJ, King BA, Caraballo RS, Bunnell RE, Babb SD, Garrett BE, Sosnoff CS, Wang L, Centers for Disease C, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke–United States, 1999–2012. MMWR Morb Mortal Wkly Rep. 2015;64(4):103–8.
Division HaHES, Bureau USC: How the Census Bureau measures poverty (official measure). In.; 2009.
Taylor AE, Richmond RC, Palviainen T, Loukola A, Wootton RE, Kaprio J, Relton CL, Davey Smith G, Munafò MR. The effect of body mass index on smoking behaviour and nicotine metabolism: a Mendelian randomization study. Hum Mol Genet. 2019;28(8):1322–30.
Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC growth charts: United States. Adv Data. 2000;314(314):1–27.
Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics. 2007;120(Supplement_4):S193-228.
Tamhane AR, Westfall AO, Burkholder GA, Cutter GR. Prevalence odds ratio versus prevalence ratio: choice comes with consequences. Stat Med. 2016;35(30):5730–5.
White VM, Warne CD, Spittal MJ, Durkin S, Purcell K, Wakefield MA. What impact have tobacco control policies, cigarette price and tobacco control programme funding had on Australian adolescents’ smoking? Findings over a 15-year period. Addiction. 2011;106(8):1493–502.
White VM, Durkin SJ, Coomber K, Wakefield MA. What is the role of tobacco control advertising intensity and duration in reducing adolescent smoking prevalence? Findings from 16 years of tobacco control mass media advertising in Australia. Tob Control. 2015;24(2):198–204.
Pampel FC, Aguilar J. Changes in youth smoking, 1976–2002: a time-series analysis. Youth Soc. 2008;39(4):453–79.
Charlton A, Bates C. Decline in teenage smoking with rise in mobile phone ownership: hypothesis. BMJ. 2000;321(7269):1155.
Jamal F, Fletcher A, Harden A, Wells H, Thomas J, Bonell C. The school environment and student health: a systematic review and meta-ethnography of qualitative research. BMC Public Health. 2013;13(1):798.
Cornell D, Huang F. Authoritative school climate and high school student risk behavior: a cross-sectional multi-level analysis of student self-reports. J Youth Adolesc. 2016;45(11):2246–59.
Settersten RA Jr, Ray B. What’s going on with young people today? The long and twisting path to adulthood. Future Child. 2010;20(1):19–41.
Caraballo RS, Sharapova SR, Asman KJ. Does a race-gender-age crossover effect exist in current cigarette smoking between non-Hispanic blacks and non-Hispanic whites? United States, 2001–2013. Nicotine Tob Res. 2016;18(Suppl 1):S41-48.
Corey CG, Dube SR, Ambrose BK, King BA, Apelberg BJ, Husten CG. Cigar smoking among U.S. students: reported use after adding brands to survey items. Am J Prev Med. 2014;47(2 Suppl 1):S28-35.
Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. N Engl J Med. 2008;358(21):2249–58.
Ball J, Sim D, Edwards R. Why has adolescent smoking declined dramatically? Trend analysis using repeat cross-sectional data from New Zealand 2002–2015. BMJ Open. 2018;8(10):e020320.
Cwalina SN, Ihenacho U, Barker J, Smiley SL, Pentz MA, Wipfli H. Advancing racial equity and social justice for black communities in US tobacco control policy. Tob Control. 2023;32(3):381–4.
Kao YH, Celestin MD, Jr., Yu Q, Moody-Thomas S, Jones-Winn K, Tseng TS: Racial and income disparities in health-related quality of life among smokers with a quit attempt in Louisiana. Medicina (Kaunas) 2019, 55(2).
Dahl E, Moody EJ, Barger B, Rosenberg S, DiGuiseppi C, Fallin MD, Lee LC, Wiggins L: Differential performance of social communication questionnaire items in African American/black vs. white children. J Autism Dev Disord 2023.
Chetty R, Hendren N, Jones MR, Porter SR. Race and economic opportunity in the United States: an intergenerational perspective*. Q J Econ. 2019;135(2):711–83.
Kegler MC, Haardörfer R, Melanson T, Allen L, Bundy LT, Kreuter MW, Williams RS, Hovell MF, Mullen PD. Steps toward scalability: illustrations from a smoke-free homes program. Health Educ Behav. 2019;46(5):773–81.
Grant T, Brigham EP, McCormack MC. Childhood origins of adult lung disease as opportunities for prevention. J Allergy Clin Immunol Pract. 2020;8(3):849–58.
Bonato M, Tiné M, Bazzan E, Biondini D, Saetta M, Baraldo S: Early airway pathological changes in children: new insights into the natural history of wheezing. J Clin Med 2019, 8(8).
Testa D, Dib M, Nunziata M, Cristofaro G, Massaro G, Marcuccio G, Motta G. Allergic rhinitis and asthma assessment of risk factors in pediatric patients: a systematic review. Int J Pediatr Otorhinolaryngol. 2020;129:109759.
Manuck TA. Racial and ethnic differences in preterm birth: a complex, multifactorial problem. Semin Perinatol. 2017;41(8):511–8.
Martinez A, de la Rosa R, Mujahid M, Thakur N. Structural racism and its pathways to asthma and atopic dermatitis. J Allergy Clin Immunol. 2021;148(5):1112–20.
Wagenknecht LE, Manolio TA, Sidney S, Burke GL, Haley NJ. Environmental tobacco smoke exposure as determined by cotinine in black and white young adults: the CARDIA Study. Environ Res. 1993;63(1):39–46.
Wagenknecht LE, Cutter GR, Haley NJ, Sidney S, Manolio TA, Hughes GH, Jacobs DR. Racial differences in serum cotinine levels among smokers in the Coronary Artery Risk Development in (Young) Adults study. Am J Public Health. 1990;80(9):1053–6.
Caraballo RS, Giovino GA, Pechacek TF, Mowery PD, Richter PA, Strauss WJ, Sharp DJ, Eriksen MP, Pirkle JL, Maurer KR. Racial and ethnic differences in serum cotinine levels of cigarette smokers: Third National Health and Nutrition Examination Survey, 1988–1991. JAMA. 1998;280(2):135–9.
Mourino N, Ruano-Ravina A, Varela Lema L, Fernandez E, Lopez MJ, Santiago-Perez MI, Rey-Brandariz J, Giraldo-Osorio A, Perez-Rios M. Serum cotinine cut-points for secondhand smoke exposure assessment in children under 5 years: a systemic review. PLoS ONE. 2022;17(5):e0267319.
The NHANES has been developed and funded by multiple federal agencies and is run by the National Center for Health Statistics. Westat, Inc. conducted the fieldwork under contract with the National Center for Health Statistics.
Conflict of Interest
The authors declare no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
What is new:
The gaps in environmental tobacco smoke exposure between races have widened, especially in heavy exposure in children. The prevalence of heavy exposure decreased by roughly 10% annually for both white and Hispanic children but remained unchanged for black children.
About this article
Cite this article
Twum, F., Tome, J., Ledel, E. et al. The Diverging Trend in Exposure to Environmental Tobacco Smoke Among US Children. J. Racial and Ethnic Health Disparities (2023). https://doi.org/10.1007/s40615-023-01645-y