Dr. Journal Club
Dr. Journal Club
Secondhand Smoke and Vaping's Impact on Children
In this episode of the Dr Journal Club podcast, we reveal the alarming statistic that one in five children are still exposed to secondhand smoke despite declining smoking rates. We dive into the differences between mainstream and sidestream smoke, explore vaping's unique mechanisms that retain 99% of nicotine, and analyze a study on nicotine absorption in children.
We also discuss the reliability of observational studies on smoking and vaping habits, highlighting the biases that can affect results, such as social desirability bias. Measuring genuine exposure levels, especially when parents smoke indoors, presents complex challenges that we scrutinize in depth.
Join us for critical insights and ethical considerations on this pressing issue. Connect with us on social media at DrJournalClub to share your thoughts and questions. Be part of our mission to explore evidence-based integrative medicine and improve public health.
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2821086
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Dr. Joshua Goldenberg:Please bear in mind that this is for educational and entertainment purposes only. Talk to your doctor before making any medical decisions, changes, etc. Everything we're talking about that's to teach you guys stuff and have fun. We are not your doctors. Also, we would love to answer your specific questions on drjournalclub. com. You can post questions and comments for specific videos, but go ahead and email us directly at josh at drjournalclubcom. That's josh at drjournalclub. com. Send us your listener questions and we will discuss it on our pod. Hello everyone and welcome to another Dr Journal Club podcast.
Dr. Adam Sadowski:Yes, sir.
Dr. Joshua Goldenberg:I'm feeling. I don't know what am I feeling. I'm feeling.
Dr. Adam Sadowski:Why are you sitting on the couch chain-smoking cigarettes while eating a TV dinner there, Josh?
Dr. Joshua Goldenberg:I'm feeling that I'm tired of doing smoking studies and when you sent this one to me, I was like not another one? Are we really doing it? Nobody smokes anymore. And then, like heartbreakingly, it said that one fifth of all kids have exposure to secondhand smoke. I couldn't believe it. To secondhand, smith, I couldn't believe it, and it just underlines what you always say about me, which is I'm completely not in touch with real life. So it's like, oh my gosh, that is just totally heartbreaking. And, yeah, this is still a problem, this is still an issue. People still smoke. People still smoke inside. People still smoke inside around kids. It's insane one in five kids are exposed to this. So, yeah, this is a super important issue.
Dr. Joshua Goldenberg:I'm glad you brought it up with one of your favorite jam and network journals. Uh, so shall we? Shall we jump in? Let's go okay, let's do it, let's do it, let's do it okay. So, um, we'll, probably. It's a pretty straightforward paper. I thought I think maybe, uh, is there anything in the introduction you wanted to talk about, or should we kind of jump into methods? What were you thinking?
Dr. Joshua Goldenberg:I think really the main thing is there is definition now for like a mainstream, versus what's known as sidestream, secondhand exposure to smoking Right no-transcript you've got and it was surprising to me that this would be so different, but I guess it makes sense because you're absorbing some of the the substances, but yeah, so, like you, you take a drag, you blow it out.
Dr. Joshua Goldenberg:That's mainstream. But meanwhile, while you're like pontificating about philosophy or why you think you look like james dean, the cigarette's still burning and I think my read this is the first I heard that phrase too that that was this, that was the smoke from, that was the side stream, uh, exposure type of thing. And then this was interesting and so, like they, they say that, in contrast to vaping, right, so, where you don't have an aerosol between puffs. So there's there, there are these unique differences between vaping and smoking that may have direct impacts on secondhand smoke, and that's kind of sets us up for this conversation and this study of. Okay, if we're talking about kids and we're interested in kiddos and their exposure to secondhand smoke, you know what kind of exposure are they getting if the people smoking inside are vaping versus smoking cigarettes? Because there's all these you know differences, mechanistic differences, between the chemicals produced.
Dr. Adam Sadowski:Right and and the reality is that the prevalence well, I guess both incidents and prevalence of vaping is increasing, increasing especially amongst our younger population, and there is some interesting background data that's suggestive of the of vaping being a quote-unquote cleaner product, where there's less, um you know, chemicals that are that are being uh released through through the vaping, and that has to do with its uh mechanism. Uh, and, shockingly, here's somewhere where I am in favor, where mechanism seems to matter.
Dr. Joshua Goldenberg:Yeah, I couldn't believe. I mean the introduction I thought was quite interesting because I didn't know any of this stuff. So, first of all, that side stream, mainstream, and then, like you said, so 99% of the nicotine is retained when you inhale from vaping versus I don't know what it is for cigarettes, but much less. So essentially you just have very efficient, I guess, absorption with vaping, and so less is then breathed out to be secondarily breathed in by by kiddos. So again you have, like you said, all these different mechanistic differences between them. And of course it's not just the nicotine. We're not really that worried about nicotine per se. We're more worried about carcinogens and other toxicants that are associated with with that, and of course that also is lower in vaping than in regular cigarette smoking.
Dr. Adam Sadowski:Exactly. And so what these authors wanted to do was look at um nicotine absorption amongst children, who are being exposed to secondhand smoke only, right to secondhand vape use only, or to those who are exposed to neither. And that makes sense. You don't want, you don't want to expose, have one group be exposed to both, because then you don't know if it's coming from the tobacco use or if it's coming from the, from the, you know, e-cigarette use, so that off the back doesn't make any sense. And it also makes sense that this was a cross-sectional study, because, one, they have data that's regularly available and then, two, you can't really like randomize participants into a smoking non-smoking or vaping non-vaping group, because that would be unethical, at least in this country.
Dr. Joshua Goldenberg:Yeah, here you go, little six-year-old kid, why don't we randomize you to go sit in this house where people are smoking all day? No, can't do that. Yeah, so, yeah. So I agree. Appropriate, appropriate study design. Um, and it's from the NHANES uh study. Do you want to? Should we talk a little bit about what that is, just so people have a sense? It's super famous continuous cohort.
Dr. Adam Sadowski:Yeah, so it's a continuous cohort, but for this particular study it's using cross-sectional data, right? So this is a cohort that's constantly being evaluated and constantly being studied. But what we're doing is we're saying, hey, we're actually just going to look at this specific time point and try to come up with an association or see if there is an association or not between an exposure and an outcome that we're interested in. So we're not like continuously monitoring them, we've kind of like monitored them within a specific, very specific period and we're just kind of taking a snapshot of this ongoing cohort. And so this is a US-based cohort and it's nationally representative. They're taking data basically across the country and specifically in this cohort they actually oversample minority populations because they know that this way they'll get a little bit more data within those participant groups, because minorities are so oftentimes underrepresented in medicine and in science, and so this is one way of actually getting a more true United States participation representation.
Dr. Adam Sadowski:And NHANES stands for the National Health and Nutrition Examination Survey, and what they used specifically in this study was looking at children within this cohort. But really, because if you're a three-year-old you're unlikely to actually be able to understand what's going on they used what they refer to as proxy participants. Basically, they asked the legal guardian of the house, or someone in the house who is constantly around the children, to provide the answers to the questionnaires that were asked. And so, within this cohort, basically, they're they're constantly asking all sorts of questions what are you eating? How much are you exercising? What are you exposed to? Do you do this, do you do that? Um, and continuously asking them on a I don't know if it's a yearly basis or every two years, or how frequently they're asking them, but, um, it's. They're just constantly getting you know a data from, from, from people.
Dr. Joshua Goldenberg:Yeah, and it's a super high quality study going on over many, many, many, many years. And an additional benefit to that besides, like you said, oversampling minority groups and being a truly representative national sample is that it also gets objective data. So, like they go in and get these high quality, you know survey results, but then they'll go in their, their clinical unit will go in and draw like lots of blood and in this case there's a blood marker for nicotine exposure that they were looking at. So they're basically trying to say, okay, let's get a sense of all these kiddos, how many are exposed to smoke? If so, what type vaping or cigarettes they threw out? I think you said anyone that was exposed to both, because it'd be too confusing methodologically, and then people who are not exposed to either and then also looked at biomarkers of that nicotine exposure, to say, okay, what levels are we actually seeing in the blood of these kiddos Exactly?
Dr. Adam Sadowski:The only issue with that was you know a lot of the participants only after answering the survey. It wasn't like they answered the survey and then had blood drawn the same day. There was about a. There was a gap in time and it was kind of you know, it was over a couple of days, so they would, let's say, monday you answer the question. It was like, okay, come in on Friday. And one of the biases that we need to be aware of within this is the fact that one you're already asking a question that's viewed as unhealthy, so participants may not want to be as truthful in their answering and then from there you're going to be getting a blood sample a couple days after answering that. You know, potentially, um, it's not a loaded question, but but participants may feel like they're being judged by answering truthfully and so that may change their behavior at the time that they're getting that objective marker.
Dr. Adam Sadowski:So yeah you know they, they may be falsely lowering the amount that they're, that the levels of nicotine in their blood if they've decided to stop smoking or stop vaping. And it's what's referred to as the social desirability bias. You're going to be answering questions based off of what current social norms are and having a more socially desirable answer. You may feel ashamed or embarrassed of being like, yeah, I smoke inside the house with children. I know it's not good for them, but I do it type of thing, and so that may stoke some emotions in these participants who are like, actually, you know what I answered that question, I'm going to stop smoking, and then they just so happen to get those labs that you know in a couple of days. So that's one thing that we do have to be aware of.
Dr. Joshua Goldenberg:Interesting in a couple of days. So that's one thing that we do have to be aware of. Interesting, yeah, that's a neat, that's interesting. I mean I thought I thought I was thinking about the first part, but not the second part. That's very interesting.
Dr. Joshua Goldenberg:So not only could people untruthfully answer the question basically say, oh no, no, no, there's, there's no exposure to the to smoke in this household. So that would be one thing because the social desirability, but the other is they might even change their behavior just by being asked that Interesting, and then the blood marker a few days later will be artificially lowered. That's very interesting, okay. So if that's true, and then what you would really have a problem with because here we're trying to compare vaping versus no smoke exposure, versus regular cigarettes is if people who are smoking cigarettes in the house versus vaping in the house, if they feel different guilt or different judgments in that way and maybe they do maybe vaping is more socially acceptable. So the cigarette smoking households are more likely to maybe answer less honestly and or change behavior.
Dr. Joshua Goldenberg:Huh, that is interesting. So not only is there a potential mechanism for that, but you can make an argument that it would be differentially affected, the different groups. Yeah, really good point, man. Yeah, really really good point. I don't know how you get around that. I mean besides immediately sampling right away for that latter point. But that just may not be pragmatic.
Dr. Adam Sadowski:Yeah, I think it's just also, you know, this is the one of the problems that you just have to accept. Uh, when it comes to observational studies, especially cross, uh, cross-sectional studies, is you just? Hey, this is a reality, you know, interpret with caution and this is something that we just is unavoidable. Yeah, and to clarify when, when they looked at participants in the study, when, when they they asked them, do you smoke inside the house? It wasn't like, hey, do you go outside on the porch to smoke, to go away from your children, or do you go into an unattached garage or do you step outside and close the door and then come back in. This was do you like smoke on the couch with children in the house, or like smoke in the kitchen? Like very much like what was normal, I guess, in the 70s and 80s, um, and, and that's kind of like what they were looking at, because and that makes sense too, because if you think about, like, comparing that to vaping, people aren't excusing themselves to go outside to vape they're just puffing like right then and there, and so I think that that that actually kind of is a strength in how they're and how they're questioning. So, although it may not necessarily be 100 pragmatic and totally how, like what I've seen most people do for those who are smokers like most people who I know that are smokers and smoke at home do excuse themselves and go outside or or only smoke in a basement or that's unattached um, or will smoke on the porch and then come back inside. So you are limiting that exposure to a certain extent, um, but in this, in this instance, they're they're doing like very much old school, like hey, are you smoking on the couch actually in inside the house, without excusing yourself.
Dr. Joshua Goldenberg:Yeah, really good points. First of all, it's just shocking that even that level is still a one fifth of kids are exposed to. That is it's mind blowing. But yeah, really excellent point, because that word we're not asking people do you smoke or vape it's? Are you doing that in the house? And you're right, because folks that they are maybe more likely perhaps do that in the house and so you're still comparing like to like. Yeah, really really good points. I love all of that. I think that's definitely a strength and also kind of shocking and, to your point, still very, very relevant unfortunately in our society, and I think it may even be worse in a lot of other countries.
Dr. Joshua Goldenberg:Look, the thing is we don't do this for money. This is pro bono and, quite honestly, the mothership kind of ekes it out every month or so, right? So we do this because we care about this, we think it's important, we think that integrating, evidence-based medicine and integrative medicine is essential and there just aren't other resources out there. The moment we find something that does it better, we'll probably drop it. We're busy folks, but right now this is what's out there, unfortunately. That's it, and so we're going to keep on fighting that good fight and if you believe in that, if you believe in intellectual honesty in the profession and integrative medicine and being an integrative provider and bringing that into the integrative space, please help us, and you can help us by becoming a member on Dr Journal Club.
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Dr. Joshua Goldenberg:Okay, cool, so I think we talked about that. Covariates, I think, yeah go ahead.
Dr. Adam Sadowski:Another thing that was important, too, was what'd you think of the response rates?
Dr. Joshua Goldenberg:Yeah, that was kind of interesting pretty darn low. So we have response rates of 63% for one to five year olds and 59% for six to 11 year olds. So I mean, you're like that's horrific, right? So normally when you do a risk of bias assessment for surveys, for survey data, for prevalence data which is essentially what this is anything any response rate less than like 80% is usually right away marked as a high risk of bias. And so you're, you're missing like 40% of respondents here, and so, especially with such a loaded although they were sitting it wasn't just this one question, right? I'm assuming this is a response rate for the entire NHANES questionnaire, and so you know you could make an argument. Yeah, it's less strong of an argument as far as like oh, I don't want to answer about the smoking situation, because it's just a general survey in general that they're being asked to fill out. Right, that was my read anyway.
Dr. Adam Sadowski:Um, I don't. I don't know one way or the other of that, but I also thought it was interesting that, although those response rates were low, the participation within the mobile um, like lab draw sites, was high right so of those 63% and 59%, it was 92% and 89% who got their labs drawn.
Dr. Joshua Goldenberg:Yeah, so if you answered the survey, you pretty much also got all that clinical data. But just very few people even signed up to do that. But it is nice that it's kind of it tracks together. The people that were in were all in, if you will. Yeah, and I am concerned. It's a good point. It's a very, very low response rate and I think that, yeah, I mean I don't know what you're supposed to do about that. Like this is extremely representative US sample, extremely well conducted, and I think it's just hard to get people to answer these like really onerous surveys, and especially when you're like asking about kids, I guess. So from a quality of study perspective, like it's hard to judge the scientists, right, but from a risk of bias perspective, it's like how could you not view that as a high risk of bias just off the bat, right? Just the fact that we're missing so much data.
Dr. Adam Sadowski:Right, right. And then the reason why they use children between three to 11 years is because they just didn't have any sort of it looks like they didn't have continine labs for, like a reference range for those who are between birth and two years old.
Dr. Joshua Goldenberg:Yeah, so that's what they use. So this, that was a new substance to me. What did you call it? Continine? Continine, yeah, uh, so that's. It is a nicotine marker, but apparently a better choice for secondhand smoke exposure, which I found interesting. I was not familiar with that biomarker before, but specifically to kind of measure the secondhand exposure. And then another cool thing about that is, um, if they saw levels were so high that it could could only be explained by actually smoking like, let's say, a 10 year old was sneaking out to get a cigarette they would throw that data out, right, so they could tell that it was only secondhand smoke, that they were measuring there. And then they would basically say we're you know, obviously this would be confounded if you're actually smoking, so we're going to throw that information out. Yeah, exactly, cool. Okay, well, that I'm good with that. Should we jump into the results? Anything else for methods you want to chat about?
Dr. Adam Sadowski:When they did their analyses they adjusted for age, sex, ethnicity, income, body weight and height. And yeah, let's jump into the results. So basically, 1,827 children were surveyed and then they ended up with an actual analysis sample of 1,777. And then dropouts were due to constant exposure just being too high to be actually realistic. And then dropouts were due to constant exposures just being too high to be actually like realistic. And then some people were exposed to both secondhand smoke and secondhand vapor. And then there were 12 children, which was just less than 1% of those included in the study, had missing body weight or height, and so they just excluded them from that. So of the 1,827 who were included, just about 15% were exposed to secondhand tobacco smoke only, and then 2.5% to secondhand e-cigarette only and then the rest, so just a little bit over 80% were exposed to neither tobacco or vaping use.
Dr. Joshua Goldenberg:Yeah, interesting, yeah, so there you go. So 20% one in five kiddos exposed pretty insanely high levels. Okay, so let's jump into I want to jump into the actual results here, if that's okay.
Dr. Adam Sadowski:Yeah, before we get into that, the mean age was 7 1⁄2 plus or minus 2 1⁄2. It was basically 50-50 between male and female. 30% were below the federal poverty line, which is a pretty high amount, and then it was pretty evenly distributed amongst Hispanic, non-hispanic Black and non-Hispanic Whites, and then 18% were reported as multiracial. And I think it was pretty interesting to see, when we look at table one, looking at that demographic table, the number of participants or the proportion of participants who were exposed to smoke only seem to be of of a greater minority background. Um, more were below the poverty line.
Dr. Adam Sadowski:So when we look at those who are exposed to smoke only, cigarette smoke only 46 percent were yeah, oh, I see what you're saying vapor versus smoke, gotcha, yeah, 46 percent were below poverty, whereas those who were exposed to vapor, only 16 percent were below poverty. Um, so I thought that was pretty interesting. Um, when we look at, uh, like the, the race and ethnicity, basically everything is double relative to those who are exposed to to vapor only, and I just thought that you know that it was interesting. That that's kind of how it was broken down, but, um, in the analyses they did adjust for this, so right yeah, yeah, yeah, yeah, no, interesting indeed.
Dr. Joshua Goldenberg:And again, I feel, methodologically I'm okay with it. Um and so probably for the, you know, let's just look at the actual. So the actual numbers probably aren't going to mean much to you, unless you're very used to seeing these um, these particular biomarkers, but let's just kind of talk them through so. So the highest exposure were for kiddos that were exposed to secondhand smoke only, which was 0.494 micrograms per liter. Okay, so that's our, that's our actual smoke. So cigarette smoke, we're at 0.494.
Dr. Adam Sadowski:That's also the unadjusted. When we look at the adjusted um it's, it is reduced a little bit, but the point remains the same.
Dr. Joshua Goldenberg:Yeah, so okay. So maybe we'll just talk relative numbers then, because maybe that makes more sense. But essentially you have a dramatic, dramatic difference between only smoke versus only vapor, like 80% reduction, like absolutely dramatic difference. If you look in the, if you're following with us in the paper, we're in figure. I think that's figure one. It's just you just see this very, very dramatic drop from only smoke to only vapor of about 80%. Now that is a 90% drop if you compare it to neither.
Dr. Joshua Goldenberg:So people that are not exposed they're still going to pick stuff up in the environment, or maybe this it's measurement error or something like that. So there's still a little bit in the blood. And you obviously see a dramatic difference between no smoke or vapor exposure and only smoke. But the difference between vapor and only smoke is, just to me anyway, mind-blowingly different. However, the vapor itself, compared to no exposure, is also statistically significantly different. So it's not like it's without risk. It's definitely better to not have vapor exposure. But when you're looking at, okay, should we expose the kiddos to cigarette, smoke or vapor? It is just. It seems to me like this, just a no, it's a no brainer. If you're replacing one for the other, right, obviously nothing is better, but if you're replacing one for the other, like 80% difference there.
Dr. Adam Sadowski:Yeah, I think there's a real conversation to be had that if you're someone who is a current smoker and you are smoking in the house and you have children, I you know, I don't think it's unreasonable to have that conversation of you know, is it healthier to switch from tobacco smoke to then vaping, even if you're trading one for the other and if you're kind of looking for like what's the lesser evil? It seems to be based on the literature that that's out there, that switching from from smoking cigarettes to e-cigarette products may perhaps be better, even if it may not change sort of like that nicotine addiction, because you're being exposed to fewer carcinogens and not by, like, just a little bit amount. It seems to be a dramatic reduction, and then those around you are also getting a significantly reduced exposure as well.
Dr. Joshua Goldenberg:Yeah, I mean this. This kind of is in line with the overall theme, I would say, of like all the smoking and vaping papers we've done, which is, when you compare it to cigarette smoke, it is seems to be a better choice. But obviously if on the table is not smoking or not vaping, that is better. However, if that is not on the table, it seems to me anyway like a pretty clear choice. And actually this dramatic difference really underscores the benefits, right, because this is looking just at the nicotine exposure and using that as a proxy for the really harmful toxicants that we're actually worried about.
Dr. Joshua Goldenberg:Again, we're less worried about nicotine exposure per se, it's more everything else that comes with it. So they're using that as a proxy for exposure for everything else in the smoke or in the in the vapor. However, to your point, vapor itself has less of those chemicals, right? So it's even going to be less harmful exposure than what it seems like on this graph. So we're probably going to have even more than an 80% difference in exposure there. So, again, we know secondhand exposure is dangerous, but just a dramatic difference. And if you're not willing to step outside or to a detached garage or something like this, then switching to vapor just would have a dramatic impact on the exposure to those kiddos.
Dr. Adam Sadowski:Yeah, no, I thought, I thought, I know, I thought it was an interesting study.
Dr. Joshua Goldenberg:Yeah, you know, I really I have this bias of this. You know, you know the phrase like don't make the perfect the enemy of the good, like I really believe in that pretty strongly. And I hear the argument that some people make that with addiction it's you need to be all in or all out, right, I've heard that argument before and certainly that was true for me with cigarettes. But I think I don't know if you're not going to quit. You know it feels weird saying, okay, it's okay to vape, but actually maybe it is right Compared to the alternative, and we don't want to make the perfect the enemy of the good. And if just like berating people to just be like, well, go outside, why aren't you going outside? Or just quit, why aren't you quitting? I don't know that that works, but maybe it does. But if that's not working, then at least getting them to switch to vaping can have a dramatic impact at least on the kids and I'm sure on them as well.
Dr. Adam Sadowski:Yeah, yeah. No, I thought it was an interesting paper. It's open access, free for anyone to go look at, you don't need a paywall. And it was not funded by any sort of industry. It was all through grant funding, so this is publicly funded paper.
Dr. Joshua Goldenberg:Very nice, very nice. I will send Michelle the link and thanks. Sort of a short and sweet paper today, very straightforward, good paper, besides that response rate, which I think you were very wise to point out, and I think that's all I got for you guys today. Very wise to point out, and I think that's all I got for you guys today. How about you, adam, anything else you wanted?
Dr. Adam Sadowski:to end on Nope, that's it. If anyone wants more of a visual or a deeper dive, I do expect to see this one on the Dr Journal Club website. There will be graphs and a little bit more attention to data visualization there, if you're interested.
Dr. Joshua Goldenberg:Beautiful. All right, thank you, Adam, and I will see you next week.
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Dr. Joshua Goldenberg:Hey hey . y'all.
Dr. Joshua Goldenberg:This is Josh. You know we talked about some really interesting stuff today. I think one of the things we're going to do that's relevant. There is a course we have on Dr Journal Club called the EBM Boot Camp. That's really meant for clinicians to sort of help them understand how to critically evaluate the literature, etc. Etc. Some of the things that we've been talking about today. .
Dr. Joshua Goldenberg:Go ahead and check out the show notes link. We're going to link to it directly. I think it might be of interest. Don't forget to wwwdrjournalclub. com follow us on social and interact with us on social media at DrJournalClub DrJournalClub on Twitter. We're on Facebook, we're on LinkedIn, etc. Etc. So please reach out to us. We always love to talk to our fans and our listeners. If you have any specific questions you like to ask us about research evidence, being a clinician, etc. Don't hesitate to ask. And then, of course, if you have any topics that you'd like us to cover on the pod, please let us know as well thank you for listening to the doctor journal club podcast, the show that goes under the hood of evidence-based integrative medicine.
Introducer:We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Be sure to visit wwwdoctorjournalclubcom to learn more.