How dangerous is second-hand smoke

Indoor air and passive smoke


Of all the harmful indoor air pollutants to which we are involuntarily exposed in Europe, passive smoke is the most common cause of illness and death: In Austria, an average of 3 people per day die because others smoke, and even more people therefore develop cardiovascular and pulmonary diseases as well of cancer. The statutory smoking ban planned for May 1, 2018 at all workplaces with the introduction of a smoke-free restaurant would lead to a sustained decrease in heart attacks of around 15% and a sustained decrease in cerebral insults, chronic obstructive pulmonary disease (COPD), cancer and metabolic disorders within one year. Studies in Europe and North America have shown a significant decrease in premature births and childhood asthma, as secondhand smoke was perceived as air pollution due to the ban on smoking in restaurants and smoking in public was increasingly denormalized. In this way, the social acceptance of smoking in the presence of children and pregnant women decreased. The repeal of this law passed in Austria in 2015 is unprecedented and only benefits the tobacco industry. It facilitates the seduction of young people into active smoking and makes it more difficult for smokers to quit nicotine addiction or to reduce their tobacco consumption. The improvement of youth protection promised by the federal states cannot compensate for the wrong decision at federal level. Previous controls of partial smoking bans in gastronomy, the age controls at points of sale for tobacco products by the monopoly administration and electronically for cigarette machines proved to be largely ineffective. The WHO, the World Bank and the Austrian medical profession are therefore calling for legal and fiscal measures to reduce the prevalence of smokers, which have proven their worth in Australia, North America, Western and Northern Europe. A representative survey commissioned by the medical initiative in 2018 showed that 70% of the Austrian population would like smoke-free gastronomy.


A number of indoor air pollutants are a health risk in Europe, but in Austria second-hand smoke (SHS) is the most frequent cause of disease and death. An average of 3 persons per day die because of exposure to SHS, and even more suffer from SHS-induced cardiovascular and pulmonary diseases or cancer. On 1 May 2018 a smoking ban was planned to come into force for all indoor places of work and public places including the gastronomy industry. It is estimated that this will reduce coronary syndrome and myocardial infarction by approximately 15% within 1 year and lead to sustainable decreases in stroke, chronic obstructive pulmonary disease (COPD), cancer and diabetes. Studies in Europe and North America also showed a decrease in premature births and asthma hospital admissions of children. Because people recognized tobacco smoke as an air pollutant, smoking in public was denormalized and social acceptance of smoking in front of children and pregnant women decreased. The unprecedented cancellation of a tobacco control law, which had been passed by parliament in 2015, would only benefit the tobacco industry, help to encourage adolescents to start smoking and make it more difficult for smokers to reduce or abstain from tobacco consumption. The provincial governments announced an improvement of youth protection but this cannot compensate for the wrong decision by the federal government. Up to now control of partial smoking bans in the gastronomy industry, age controls in tobacco shops and by the monopoly administration and electronic age control by vending machines largely failed. The World Health Organization (WHO), the World Bank and the Austrian medical profession therefore demand legislation and taxation to reduce smoking prevalence, measures which proved to be successful in Australia, North America, Western Europe and in neighboring countries. A representative survey commissioned by the Austrian Council on Smoking and Health, proved that 70% of the Austrian population are in favor of smoke-free restaurants and bars.

Indoor air

In our culture, most people spend more than 80% of their life indoors. For small children, the sick and other sensitive groups of people, the quality of the indoor air is particularly important because they spend a long time in certain indoor spaces. Pollutants from the outside air penetrate to different degrees into the interior and are z. T. bound to surfaces and transformed. Without any sources of pollution, z. B. only about 30% of the ozone concentration that is measured outside in summer, which led to the recommendation to leave children at home when there is an ozone warning. However, if they are exposed to secondhand smoke from cigarettes there, their exposure is much higher than if they were playing outside during the ozone warning. Gaseous pollutants from winter smog such as sulfur dioxide are also measured in significantly higher concentrations outside than inside, provided that no combustion processes take place inside (e.g. in open chimneys). Fine dust with a particle size of around 100 nm can penetrate up to 70% of the interior spaces even with the windows closed, larger and smaller particles to a lower percentage. However, there are often separate sources of pollution not only in work rooms, but also in living rooms, which allow the indoor concentrations to reach a multiple of the outdoor concentrations if there is no adequate ventilation. Organic air pollutants in particular are usually found in higher concentrations inside than outside and often come from building and insulation materials, adhesives, sealants, chipboard, wooden surfaces, surface coatings, floor coverings, plastics (plasticizers), electrical appliances (flame retardants) and household chemicals in apartments ( Solvents and cleaning agents, craft material). Carbon monoxide from ovens and water heaters with a defective hood can be acutely life-threatening. Gas flames emit nitrogen oxides and formaldehyde, which can be a health risk in a small kitchen with tight windows. Every flame (even that of a small instantaneous water heater) and also the cooking vapors need a hood. Open chimneys, scented candles and incense sticks are not recommended. Increased ventilation is necessary in new buildings because of the residual moisture from building materials as well as in tight buildings so that mold growth and contamination of the room air with fungal spores do not occur on cold bridges. Allergies can also occur from indoor plants, but more often from the excrement of the house dust mite, which accumulates in mattresses, bedding, upholstered furniture, carpets, etc.

"Limit values ​​for carcinogens or fine dust without health risk do not exist"

A particular cancer risk is posed by the noble gas radon, which penetrates into residential buildings from the ground (via foundations, cellars, water pipes, etc.). Its radioactive daughters are inhaled adsorbed on fine dust and irradiate the lungs from the inside. Lung cancer as a long-term consequence decreases by about 10% per 100 Bq / m3 Air to. High cancer rates are to be expected primarily from the combination of tobacco smoke, radon and fine dust.

Solid-fuel heating systems also contribute to fine dust and carcinogen pollution: The wood heating system, propagated for reasons of climate protection, allows fine dust and benzo (a) pyrene in the outside air to rise again, but these pollutants can not only pass through the windows, but also (e.g. from open Chimneys) get directly into the room air. Influences of wood smoke on heart rhythm, blood clotting, oxidative stress, inflammation and immunosuppression (increased susceptibility to infection) have been proven (similar to fine dust from other sources) and in areas with wood smoke pollution, endothelial function and signs of inflammation improved after one week of filtering the room air in living rooms and bedrooms. When trying to reduce pyrolysis products through more complete combustion and fine dust through filters, it should be noted that there are no limit values ​​for either carcinogens or fine dust below which there is no health risk. However, high health risks from burning biomass indoors exist only from heating and cooking areas in developing countries where no chimneys are used [16].

The Climate and Air Quality Commission of the Austrian Academy of Sciences will publish a more comprehensive overview of indoor climate, pollutants and odors that are relevant for Austria in 2018 in the form of a brochure [7].

Secondhand smoke

The most common life-threatening air pollution in developed countries is passive smoke ("environmental tobacco smoke", ETS, "second hand smoke", SHS; [5]). The source strength of the pollutants escaping from the cigarette holder is so high that the number of air changes would have to reach storm strength in order to keep the health risk within acceptable limits. Only after the last smoker has left a restaurant does the air pollution from ventilation systems drop to acceptable levels. Three cigarettes, smoldering one after the other in the ashtray, led to a 60 m3 large room with fine dust concentrations 10 times higher for one hour than a car diesel engine running for 30 minutes in the same room. In addition, the sidestream smoke from the cigarette holder contains much higher concentrations of cancer-promoting pollutants (e.g. tobacco-specific nitrosamines) than the mainstream smoke, which the smoker voluntarily inhales because the combustion temperature is lower during breaks. The particle size in sidestream smoke is also smaller and therefore its surface area with which it comes into contact with the surfaces of the mucous membrane is larger. Some of the smallest particles also get into the blood via the alveoli and thus into all organs. No thresholds were detectable for the effect of respirable particles on the cardiovascular system or for carcinogens, below which there is no risk, but the dose-effect curves should run through the zero point and are steeper for tobacco smoke in the lower concentration range. Smoking a single cigarette per day is associated with about half the increase in risk of heart attack and stroke as smoking 20 cigarettes per day and regular passive smoking increases ischemic heart disease to the same extent as light active smoking [6, 14]. Fig. 1 provides an overview of the illnesses and complaints caused or exacerbated by passive smoking in adults.

Passive smoking in gastronomy

On working days, non-smoking employees in the hospitality industry excrete up to 25 times more nicotine in their urine than on their days off and up to 4.5 times more tobacco-specific carcinogens. The most potent lung carcinogen, tobacco smoke, increases by 6% per hour worked in the urine of non-smoking waiters. Even on non-working days, an increased excretion of cancer-promoting nitrosamines in the urine of these workers who involuntarily have to inhale tobacco smoke can still be detected. Passive smokers can also use the sidestream smoke to generate considerable doses of polonium 210 (210Buttocks), which then irradiates your lungs from the inside. Regular passive smokers such as Kellner develop a significantly increased risk of cancer: in the bronchi (all forms of cancer, but especially adenocarcinoma and small cell lung cancer), sinuses, larynx and nasopharynx (especially in combination with alcohol), urinary bladder, cervix (combined effect of human papilloma viruses with nicotine) , Mammary gland (especially from secondhand smoke during the development of the breast) and other locations. Even if waiters were not seduced into active smoking when they were apprentices, their risk of lung cancer doubles after about 8 years if they work in smoking rooms. They also develop an increased risk of cardiovascular diseases (heart attack, stroke) and COPD (chronic obstructive pulmonary disease), which contributes to their chronic morbidity, early disability and premature death to an even greater extent than the cancers. Waitresses can be denied the desire to have children through passive smoking, and in the event of pregnancy, passive smoking by the mother also endangers the child's healthy development [8, 14].

A significant decrease in lung function can already be demonstrated in the course of a work shift in catering staff with passive smoke exposure. After the introduction of a smoking ban, lung function improves significantly. Nicotine disappears from the air after a smoking ban, as do nicotine breakdown products from the blood and saliva and the tobacco-specific carcinogens from the urine; the heart rhythm normalizes and the stiffness of the arteries decreases. Coughs and breathing difficulties decrease significantly in gastronomy after smoking bans. The risk of lung cancer can increase tenfold in 40 years of service if you serve in a smoking place. Never smokers with lung cancer should always be asked about passive smoking and, if suspected, reported as an occupational disease (in Austria according to Section 177 (2) ASVG).

"The highest cardiovascular risk results from tobacco smoke and fine dust pollution of the outside air combined"

In Austria's restaurants one often only has the choice between a smoking zone and a passive smoking zone [1, 20]. This is because smoke from the smoking area regularly penetrates (and often in concentrations that are hazardous to health) into the non-smoking area, which is only separated by a passage door, where families with children are pretended to be safe with the non-smoking sign [2]. Asthma and heart patients are even acutely at risk from tobacco smoke in pubs: In the USA, the health authorities warned coronary patients not to enter smoky pubs, because in a smoking room it can be enough time to eat in a person who has suffered from vagal and acute inflammatory reactions and endothelial dysfunction and increase in blood clotting triggering a heart attack. Acute effects are compensated for in healthy people, but coronary and cerebral sclerosis gradually develops in a smoky atmosphere. The fine dust pollution in smoking rooms is many times higher than outside on a busy street, but the highest cardiovascular risk develops when tobacco smoke and fine dust pollution of the outside air from heating, traffic and industrial exhaust gases come together [3, 9, 10, 11, 12, 13 .22]

Unborn babies, children and adolescents

If an embryo or fetus is exposed to nicotine or other pollutants contained in tobacco smoke during its development, developmental damage results which have been summarized as "fetal tobacco syndrome" and which often only become noticeable later in life, especially in the lungs (reduced vital capacity) and brain ( reduced learning performance; Tab. 1).

The sensitivity to traffic emissions (NO2, PM10) increases after early passive smoking (in the womb and as a toddler) and leads to a higher risk of asthma. Both fine dust from the city air and passive smoking increase blood pressure. Similar damage to the arteries from passive smoke and concentrated city air has been demonstrated experimentally, with damage from passive smoke reaching the same extent for as little as 30% of the particulate matter in the city air. The expandability of the small arteries already suffers in children, both from passive smoking and from urban fine dust. Even in childhood, cerebral arteries age 3 years faster due to passive smoking. Only as a long-term consequence can one see an increase in calcification of the cerebral vessels and the coronary arteries (whereby even light passive smoking is associated with an increase in the calcium score of 54%, moderate passive smoking with 60% and heavy passive smoking with 93%). Atherosclerosis and its sequelae are also promoted by metabolic disorders, which in turn are caused or aggravated by tobacco smoke: Compared to adolescents in a smoke-free environment, the metabolic syndrome occurs up to 6 times more often in smokers and up to 4 times more often if they only smoke passively. Tobacco smoke makes the cells less sensitive to insulin, which could explain that smokers have higher blood sugar levels on average and are more likely to develop type 2 diabetes. Adults who smoke are around 50% more likely to develop diabetes than non-smokers. Passive smokers increase the risk of diabetes by 22–33%. If the diabetic continues to smoke after the diagnosis, he doubles or triples his risk of heart attacks, strokes, kidney failure, blindness and amputations.

"The lethal consequence of passive smoking for young children is sudden infant death"

Pregnant women who smoke are more likely to have premature births and stillbirths. In addition, the perinatal mortality of children is also increased. The lethal consequences of passive smoking for small children are sudden infant death (SIDS) due to a serotonin deficiency in the brain stem as well as pneumonia, which are more often fatal in smoker households. Smoking parents and caregivers are also a contributory cause of other life-threatening infectious diseases such as B. Meningitis (meningococci can be spread to the child from a smoker's kiss).The less dramatic but common consequences of secondhand smoke for children are otitis media. The aerosol that users of e-cigarettes exhale also pollutes children with nicotine and this leaves indelible traces in their brains, as animal experiments have shown [8, 14].


The use of e-cigarettes also pollutes the room air with fine and ultra-fine dust, with inhalation-toxic aromas and solvents, with traces of carcinogens (formaldehyde, nitrosamines, PAH, heavy metals), with nicotine and z. Sometimes with additives that have already been banned for tobacco cigarettes. Nicotine, which is absorbed in a similar amount during "passive vaping" as during passive smoking, is toxic to the vessels and promotes cancer (by inhibiting apoptosis, stimulating cell proliferation and angiogenesis). Recently, nicotine has also been shown to have mutagenic effects on the mucin genes. In animal experiments and in human cell cultures, the e-cigarette aerosol caused DNA damage in lung and bladder cells similar to that of tobacco smoke, which was attributed to nicotine and its nitration product NNK (nicotine-derived nitrosamine ketones). Furthermore, changes were found in such experiments which suggest a role of the e-cigarette aerosol in the pathogenesis of COPD. Irritants from nicotine-free e-cigarettes such as acrolein, propylene glycol and, above all, fine and ultra-fine dust are also harmful. E-cigarettes can even produce more ultra-fine dust than conventional cigarettes (aerosols with reactive oxygen radicals) and, due to oxidative stress, lead to an inflammatory reaction in the airways and arteries, similar to PM2.5 in the outside air [2, 18, 19].

Cold tobacco smoke

Relationships to childhood asthma have been demonstrated for both the cotinine in the child's urine and the particulate matter, which is higher in smoker households. Fine dust can only be insufficiently reduced by air purifiers, and nicotine cannot be reduced at all. Smokers also carry pollutants and carcinogens into the apartment with their exhaled air, on hair, skin and clothing, which can be detected in the air, in house dust and on surfaces and from there are released back into the room air. Tobacco-specific nitrosamines increase with the aging of cold smoke, are long-lived in house dust and put children at risk. The half-life of nicotine in fingerprints is only short, but other toxins can be detected for over 6 months. This “third hand smoke” (THS) causes oxidative stress, hormonal disorders and increased insulin resistance in animal experiments and could therefore be a risk factor for later type 2 diabetes even in children (in addition to diet). The worst is second-hand smoke, such as smoking in a car [17] or in the home, but it must be borne in mind that passive smoke leaves a contamination in spite of ventilation. Mutagens and carcinogens from cigarettes are very long-lasting on carpets, upholstered furniture, wallpaper, bedding, stuffed animals, etc., are not removed even by repeated ventilation and are ingested by children through breathing air, skin contact and orally (playing on the floor, house dust, etc.). The exposure of children to heavy metals is also increased in households with smokers. Toxic effects of the deposited THS have so far only been proven in animal experiments; it showed z. B. an effect on the immune system and an increased tendency to thrombosis [14].

Health consequences of smoking bans

The consistent introduction of smoking bans at all workplaces and in publicly accessible areas, including restaurants, led to a 10–20% decline in ischemic heart disease in the population within a year. Heart attacks, cerebral infarctions and COPD also decreased steadily, with stricter measures having a stronger effect on rescue operations, hospital admissions and mortality. The decline was more pronounced among younger nonsmokers who frequented places. In children, hospital admissions for asthma decreased by 10% and those for pneumonia and bronchitis by almost 20%. The ban on smoking in restaurants made parents aware that tobacco smoke is a dangerous air pollution, so that at home and in the car, when children were present, they were also smoked less often. With the denormalization of smoking in public, its social acceptance decreased, it was easier for smokers to quit and it was more difficult to seduce young people.

Austria - the ashtray of Europe

While politicians in Australia, North America, Northern and Western Europe and many countries in Asia (e.g. Thailand, Turkey) and South America (e.g. Brazil, Uruguay) followed the advice of medical science, the tobacco industry and trade as well as their lobbyists have still has a strong influence in Austria [5]. Since 2007, Austria has been ranked last in the European cancer leagues when it comes to tobacco control because cigarettes are cheap here - measured by purchasing power - and are available around the clock in vending machines whose electronic age control has demonstrably failed, as well as in tobacconists and other sales outlets that are only controlled by the monopoly administration and therefore also sell tobacco to minors with impunity. Tobacco sales outlets in Austria also offer goods for children who expose them to tobacco advertising, although smoking is allowed in tobacco shops in front of children. Every time the tobacco industry launches a new brand, free cigarettes are allowed to be distributed there. Health Minister Dr. Ausserwinkler drafted the then most modern tobacco law in Europe in 1992 and announced it internationally at a WHO conference in Vienna in 1993, but fell victim to an intrigue by the then Minister of Economics in 1994, who ensured that the law passed in 1995 remained unpunished. After this minister became Chancellor in 2000, he prevented any further progress in tobacco control that was not enforced by EU directives. The tobacco industry brought more and more temptations to the Austrian market, smoking rates among children and adolescents rose dramatically and smoking began earlier and earlier. Nevertheless, the WHO Framework Convention on Tobacco Control, which Austria ratified in 2005, has not yet been implemented (in particular Art. 5.3 and Art. 8), EU directives have only been met at the latest possible point in time and EU recommendations such as those in the EU Official Journal C 296 of December 5, 2009, largely ignored. Only since 2008 have there been sanctions in Austria for violating smoking bans in publicly accessible indoor spaces; however, one-room restaurants are up to 50 m2 as well as smoking rooms excluded. Spain, from which this regulation was adopted on the advice of an FPÖ MP, has learned from the failure of such partial smoking bans and amended its law in 2010. In Austria, it took a health minister who was diagnosed with cancer herself and a popular journalist with lung cancer for a smoke-free gastronomy to be finally passed in parliament in 2015 with the votes of the SPÖ, ÖVP and the Greens. The longest transition period in Europe was decided at 3 years for the “protection of trust”. The law was due to come into force on May 1, 2018. At the request of the FPÖ chairman, the coalition committee decided in December 2017 to cancel the smoke-free restaurant again [1]. The question of whether the tobacco industry supported the FPÖ and ÖVP election campaigns in 2017 appears justified in this context, but cannot be answered due to a lack of transparency in party funding.

"Austria is the only country to have a parliamentary decision to deteriorate the protection of non-smokers"

The protection of minors will be improved in 2019 thanks to a decision by the responsible state governments in March 2017 to the extent that the reference age for tobacco products and cigarettes will be raised from 16 to 18 years [21]. What is still missing, however, are implementation regulations with mystery shopping (test purchase) by an independent body and the abolition of cigarette machines, whose electronic age control failed even for 13 to 15 year olds. The Austrian federal government originally planned a ban on entry for minors in smoking rooms and rooms as well as a ban on smoking in private cars when bringing minors with them. After an objection by the tobacco lobby, only the ban on smoking in cars remained, but without sanctions for violations by the executive branch. Thus this “improvement of the protection of minors” is only a fig leaf for the abolition of the smoke-free gastronomy, which among other things should have improved the protection of minors against passive smoking and the temptation to active smoking. The government hypocritically spoke of the “Berlin model” without at least taking over the taxation levy from Berlin for smoking areas and its ban on smoking on dance floors in discos. Austria is the only country in the world whose parliament decided to worsen the protection of non-smokers, and March 22, 2018 will go down as a black day in the history of Austrian health policy.

According to a representative survey from 2018, 70% of Austrians aged 15 and over are in favor of maintaining the law with smoke-free restaurants (all age groups). The approval rates were even higher in countries with a high share of tourism (80–84%), among women (77%), academics (84%) and high school graduates (77%). Three quarters of non-smokers and ex-smokers and two thirds of occasional smokers are in favor of smoke-free gastronomy and only every second regular smoker in Austria is currently still against it. After the consistent introduction of smoke-free restaurants, the approval rates have risen significantly everywhere and in other EU countries finally achieved a majority among smokers because most of them want to reduce their tobacco consumption or quit completely, which is made easier for them by smoke-free restaurants.

Despite the wishes of the population, all governors and many mandataries of the governing parties, which was supported by all health experts, the governing parties made the votes in the National Council and the Federal Council compulsory and thus degraded members of their parliamentary group to puppets. The opposition still has the option of bringing a constitutional complaint. In addition, on February 15, 2018, the Austrian Medical Association initiated a referendum for smoke-free gastronomy ( Furthermore, it is necessary to support the federal states in protecting minors against passive smoking and against the temptation to active smoking: by abolishing vending machines, advertising and displaying cigarettes, reducing sales licenses and withdrawing licenses if the age regulations are repeatedly disregarded. In addition, tobacco taxes should be increased significantly and a fixed part of them should be devoted to tobacco prevention.

conclusion for practice

The pulmonologist has a key role in fighting the tobacco epidemic. He can do this by ...

  • Motivation of his patients to quit smoking including relapse prophylaxis, which is only convincing if he does not smoke himself.

  • Educating young patients that it is harder to quit smoking later than never starting, and advising family members, especially parents and educators, about successful methods of tobacco prevention.

  • Effective public relations work, which clarifies the health dangers of passive smoking to the media and politicians, as well as resolute action against wrong political decisions, such as this year's amendment to the Tobacco Act. The doctor has to courageously oppose corrupt politicians, but also unsuspecting politicians who pretend to defend “smokers' interests” in order to suppress their own weakness from consciousness and who serve as puppets for the tobacco companies.


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  1. Center for Public Health, Department of Environmental Hygiene and Medicine, Medical University of Vienna, Austrian Academy of Sciences (KKL), Kinderspitalgasse 15, 1090, Vienna, Austria

    Prof. Dr. M. Neuberger

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Correspondence to Prof. Dr. M. Neuberger.

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Neuberger, M. Indoor Air and Passive Smoke. Pulmonologist15, 254-262 (2018).

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  • Indoor air pollution
  • smoking ban
  • Tobacco smoke
  • Tobacco air pollution
  • Austria


  • Indoor air pollution
  • Smoke-free policy
  • Tobacco smoke
  • Tobacco air pollution
  • Austria