Prevalence and Predictors of Environmental Tobacco Smoke Exposure among Adolescents in Cambodia

Objective:

To estimate the prevalence and predictors of environmental tobacco smoke (ETS) exposure among nonsmoking adolescents in Cambodia.

Materials and Methods:

Analysis of data from the Global Youth Tobacco Survey (GYTS) conducted in 2003 in Cambodia. Data were analysed to obtain the prevalence of ETS exposure at home and elsewhere by age and gender. Logistic regression analysis was conducted to assess the association between ETS and gender, age, smoking status of parents and friends.

Results:

67.1% (64.0, 70.0) males and 67.4% (64.2, 70.5) females reported being exposed to ETS either at home or elsewhere. Adolescents who had one or both smoking parents had a more than three times the odds of ETS exposure at home (OR = 3.71; 95% CI (3.02, 4.57)). Those who had smoking friends were more likely to be exposed to ETS both at home and outside home (OR = 1.74; 95% CI (1.36, 2.24)). The overall proportion of adolescents exposed to ETS outside home was higher than those exposed at home (P < 0.001), suggesting that exposure in public areas was the main form of ETS among adolescents in Cambodia.

Conclusions:

Exposure to ETS is high among adolescent in Cambodia, which indicates an urgent need for specific measures, policies and regulations to protect nonsmoker Cambodian adolescents both within and outside home.     

Perceptions of smoking and nonsmoking peers: the value of smoker and nonsmoker prototypes in predicting smoking onset and regular smoking among adolescents.

Adolescents' perceptions of persons their age who smoke cigarettes (also known as prototypes of smoking peers) play a critical role in an adolescent's decision to start smoking. However, adolescents' perceptions of their peers who do not smoke (prototypes of nonsmoking peers) could be implicated in adolescents' smoking decisions as well. In the present study, the authors examined the additional role of nonsmoker prototypes in adolescents' smoking onset and regular smoking. At seven high schools, Dutch students (n = 1,035) between the ages of 12 and 15 years who were attending the eighth grade provided self-reported data on their smoker and nonsmoker prototypes and smoking behavior during a baseline and 6-month follow-up measurement. Logistic regression analyses showed that both smoker and nonsmoker prototypes assessed at Time 1 predicted smoking onset by Time 2 among nonsmoking adolescents. However, only nonsmoker prototypes predicted regular smoking among adolescents who smoked occasionally at baseline.     

Neonatal hair nicotine levels and fetal exposure to paternal smoking at home

Exposure to environmental tobacco smoke (ETS) is a major risk to human health, and the home is the greatest single source of ETS for children. The authors investigated fetal exposure to paternal smoking at home during pregnancy. Korean families were included as trios of fathers, mothers, and neonates identified in 2005-2007. Sixty-three trios were finally enrolled in this study after exclusion of those in which the mother was a smoker or was regularly exposed to ETS at places other than the home. Nicotine and cotinine concentrations in hair were measured by using liquid chromatography-tandem mass spectrometry to determine long-term exposure to ETS. The difference between neonatal nicotine concentrations in the smoker and nonsmoker groups was not statistically significant. However, in the indoor-smoker group, neonatal nicotine concentrations were significantly higher than in the outdoor and nonsmoker groups (P < 0.05). Furthermore, neonatal nicotine concentrations in the outdoor-smoker group were not different from those in the nonsmoker group. These findings indicate that paternal smoking inside the home leads to significant fetal and maternal exposure to ETS and may subsequently affect fetal health. Conversely, findings show that paternal smoking outside the home prevents the mother and her fetus from being exposed to ETS.     

Method for installing an effective smoking room and the effectiveness of real-time monitoring]

We investigated the methodology for installing effective smoking rooms in workplaces. It is absolutely necessary to install exhaust ventilation in smoking rooms. There are two bases for deciding the exhaust ventilation rate. The most important is to eliminate the leakage of environmental tobacco smoke (ETS) from the smoking room. An airflow rate of more than 0.2 m/s at the opening of the smoking room is required by the Guidelines for Smoking Control in Workplaces (Ministry of Labour, Welfare and Health) to eliminate the leakage. This ventilation rate is decided by multiplying the opening area by 0.2 m/s. The second important point is to keep the concentration of ETS in the smoking room less than control concentration (0.15 mg/m3). This ventilation rate is decided by dividing the rate of generation of ETS by the control concentration. It is confirmed that an effective smoking room can be installed by following these guidelines. We used real-time monitoring to evaluate the leakage of ETS from the smoking room and the ETS concentration in the smoking room before and after the improvement. It is concluded that real-time monitoring of ETS is a useful method for evaluating the effectiveness of the smoking room.     

Restrictive workplace smoking policies: impact on nonsmokers' tobacco exposure.

The health consequences of exposure to environmental tobacco smoke (ETS) are well documented. Although nonsmokers are generally aware of the health risks of ETS exposure, the majority of nonsmokers are regularly exposed. The most common source of exposure is the workplace. Restrictive workplace smoking policies are being used as a primary means of reducing ETS exposure. However, few studies have focused on the relation between workplace policy and ETS exposure. We performed two studies which examined the relationship between smoking policy, self-reported ETS exposure, and salivary cotinine concentrations. Study I, a pilot study, focused on a workplace-based sample of 106 volunteers; Study 2 examined exposure among 881 nonsmokers in workplace settings. In both studies, more restrictive workplace smoking policies were associated with a lower proportion of nonsmoking volunteers with detectable salivary cotinine. In Study 2, the larger study, the only other variable found to be significantly related to cotinine detection was the presence of smokers in the home. These results suggest that restrictive workplace smoking policies may reduce employees' overall ETS exposure.     

Restaurant smoking restrictions and environmental tobacco smoke exposure.

OBJECTIVES: This study evaluated the effectiveness of smoking restrictions. METHODS: We measured particulate concentrations in restaurants with different levels of allowable smoking. RESULTS: Mean particulate concentrations were 70% higher in establishments without smoking restrictions compared with those with partial smoking restrictions. Concentrations in nonsmoking restaurants were reduced by an additional 20% to 30%. Measurements of cadmium, an environmental tobacco smoke (ETS) marker, implicated ETS as the major source of particulate in restaurants that allowed smoking. CONCLUSIONS: Partial smoking restrictions substantially reduce, but do not eliminate, ETS exposure in restaurants. Occupants of nonsmoking restaurants avoid ETS exposure but may experience substantial particulate exposures from cooking emissions.     

The exposure of nonsmoking and smoking mothers to environmental tobacco smoke during different gestational phases and fetal growth

We studied the impact of maternal exposure to environmental tobacco smoke (ETS) on birth weight (BW), low birth weight (LBW), and intrauterine growth retardation (IUGR) according to self-reported maternal smoking habits in a sample of 6,866 singleton births. We obtained data about parental characteristics and maternal active smoking (AS) and passive smoking at delivery via maternal questionnaires and medical records. We used three categories of smoking habits (nonsmokers and those who smoked 1-10 or >10 cigarettes per day) and defined ETS exposure as greater than or equal to 5 cigarettes per day smoked by others in the mother's presence. We used multiple regression and logistic regression procedures with adjustment for many associated covariates. We observed a significant reduction of the mean BW in infants of AS mothers. This reduction was only marginal for mothers who stopped smoking after recognizing their pregnancy. ETS exposure in 1,797 of 5,507 nonsmoking mothers reduced the mean BW of their infants by 53 g [95% confidence interval (CI), 24-82 g]. ETS exposure also significantly reduced BW in babies of AS mothers by 92 g (CI, 21-113 g) compared with BW of ETS-nonexposed AS mothers. The adjusted odds ratio (AOR) of LBW for ETS-exposed AS mothers was two times the LBW risk of ETS-nonexposed AS mothers(2.02; CI, 1.11-3.67); the AOR of ETS-exposed nonsmoking mothers was 1.51 (CI, 1.02-2.26). The AOR of IUGR for this group did not differ from unity (1.08; CI, 0.82-1.43). However, ETS exposure increased the AOR of IUGR for AS mothers from 1.64 (CI, 1.06-2.53) to 2.13 (CI, 1.70-2.67). ETS exposure reduced the BW of infants of nonsmoking mothers and contributed to additional BW reduction in infants of AS mothers. ETS exposure increased the risk of LBW but not that of IUGR in babies of nonsmoking mothers.     

Cord serum cotinine as a biomarker of fetal exposure to cigarette smoke at the end of pregnancy

This study investigated the association between biomarkers of fetal exposure to cigarette smoke at the end of pregnancy, cotinine in cord serum and in maternal and newborn urine samples, and quantitative measurement of smoking intake and exposure evaluated by maternal self-reported questionnaire. Study subjects were 429 mothers and their newborns from a hospital in Barcelona, Spain. A questionnaire including smoking habits was completed in the third trimester of pregnancy and on the day of delivery. Cotinine concentration in cord serum was associated with daily exposure to nicotine in nonsmokers and with daily nicotine intake in smokers. The geometric mean of cotinine concentration in cord serum statistically discriminated between newborns from nonexposed and exposed nonsmoking mothers, and between these two classes and smokers, and furthermore was able to differentiate levels of exposure to tobacco smoke and levels of intake stratified in tertiles. Urinary cotinine levels in newborns from nonsmoking mothers exposed to more than 4 mg nicotine daily were statistically different from levels in two other categories of exposure. Cotinine concentration in urine from newborns and from mothers did not differentiate between exposure and nonexposure to environmental tobacco smoke (ETS) in nonsmoking mothers. Cord serum cotinine appeared to be the most adequate biomarker of fetal exposure to smoking at the end of pregnancy, distinguishing not only active smoking from passive smoking, but also exposure to ETS from nonexposure.     

Concentrations of nicotine, RSP, CO and CO2 in nonsmoking areas of offices ventilated by air recirculated from smoking designated areas

The exposure of nonsmokers to environmental tobacco smoke (ETS) when smoking is relegated to designated areas that are not separately ventilated is of considerable interest. Concentrations of nicotine, respirable suspended particles (RSP), carbon monoxide (CO), and carbon dioxide (CO2) were measured in offices under different conditions of smoking regulation: smoking prohibited; smoking prohibited areas receiving recirculated air from designated smoking areas; smoking and nonsmoking sections of these designated smoking areas. Nicotine was collected by pumping air for periods of 1-8 hr at 1 L/min through sampling tubes containing a styrene divinylbenzene copolymer. RSPs (5 micron cut-off) were measured using an optical side scattering instrument. CO was measured by a direct reading electrochemical analyzer and CO2 by colorimetric detector tubes. Detection of nicotine in nonsmoking office areas that received recirculated air from smoking designated areas required sampling times of 4 hr or more. Nicotine levels in such offices were approximately 1.0 micrograms/m3. RSP, CO and CO2 concentrations were approximately the same in these offices as compared to nonsmoking offices not exposed to recirculated air from smoking areas. Providing a designated but not separately ventilated smoking area appears to be effective in eliminating most components of ETS from nonsmoking office work areas.     

Determinants of children's exposure to environmental tobacco smoke (ETS): a study in Southern Germany

Maternal smoking has been repeatedly found to be the most important determinant of children's exposure to environmental tobacco smoke (ETS). Here, we further investigated predictors for the urinary cotinine/creatinine ratio (CCR, ng/mg) in 1220 preschool children for the year 1996. Children from smoking homes (35.1%) had significantly higher CCR than children from nonsmoking homes (mean: 55.5 vs. 14.9 ng/mg). The level of education of the parents was a strong predictor for CCRs even after adjusting for number of cigarettes smoked, maternal smoking and dwelling space. Additionally, dwelling space was inversely related to children's urinary cotinine level. The CCR- levels in children investigated in 1996 and 1998 were significantly correlated (Pearson's r=0.67). The parents of 806 children agreed for a visit to their homes. In 79 of the 536 (14.7%) of the self-reported, nonsmoking households, smoking was admitted during the visit. The mean urinary CCR of these children was 25.2 ng/mg. We conclude that in addition to parental smoking behaviour, other variables such as dwelling space and social and educational status predict the children's exposure to ETS. Our data also revealed that a considerable percentage of parents denied the ETS exposure of their children at home.     

Environmental Tobacco Smoke and Lung Cancer Among Chinese Nonsmoking Males: Might Adenocarcinoma Be the Culprit?

No studies have specifically reported the association of lungadenocarcinoma with environmental tobacco smoke (ETS) exposureamong nonsmoking males. The objective of this study was to examinethe exposure-response relation between ETS exposure and lungcancer among nonsmoking males. In particular, the associationwith adenocarcinoma of the lung was studied. This is a population-based,case-referent study in Hong Kong during 2004–2006. A totalof 132 Chinese male nonsmokers with newly diagnosed primarylung cancer and 536 nonsmoking community referents were interviewedabout ETS exposures from the household and/or workplace, includingever ETS exposure, sources of exposure, number of smoking cohabitants/coworkers,and smoker-years. Univariate logistic regression analyses showeda weak association between all lung cancers and ever ETS exposurefrom the household and/or workplace (odds ratio (OR) = 1.11,95% confidence interval (CI): 0.74, 1.67), but an increasedrisk was restricted to adenocarcinoma (OR = 1.68, 95% CI: 1.00,2.38). After adjustment for family cancer history and otherconfounders, excess risk (OR = 1.62, 95% CI: 0.91, 2.88) stillpersisted for adenocarcinoma, although it was no longer statisticallysignificant. Exposure-response relations for adenocarcinomawere found with increasing levels of all ETS indices when exposuresfrom the household and workplaces were combined. The consistentexposure-response relations between ETS exposures and adenocarcinomasuggested a probable causal link, which would have to be confirmedby future larger studies. adenocarcinoma; lung neoplasms; tobacco smoke pollution     

Evidence for an association between environmental tobacco smoke exposure and birthweight: a meta-analysis and new data

Because of the strong association of active smoking with fetal growth retardation, increasing interest has focused on whether there is also an association with exposure to environmental tobacco smoke (ETS). We examined this issue in a retrospective study and by conducting a review of the literature and data pooling. In our study, nonsmoking women with singleton livebirths born in 1986–87 ( n  = 992) provided information on exposure to ETS for 1 h or more per day and paternal smoking. The risk of low birthweight (LBW, < 2500 g) was not increased in infants of ETS-exposed women, but there was a somewhat increased risk for LBW at term (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 0.6, 4.8) and small-for-gestational-age (< 10th percentile of weight; OR = 1.4, 95% CI = 0.8, 2.5). These results were in the range of 16 other studies in the literature that had odds ratios from 1.0 to 2.2. A weighted average of the results of all studies on LBW at term or small-for-gestational-age yielded a pooled estimate of 1.2 [95% CI = 1.1, 1.3] in nonsmoking women. The pooled estimate of mean birthweight indicated a decrement of 28 g with ETS exposure of nonsmoking women [95% CI = −41, −16], with a greater decrement (about 40 g) seen among more homogeneous studies.     

Choosing to remain smoke-free: the experiences of adolescent girls.

PURPOSE: To develop an understanding of the experiences of nonsmoking girls and determine how these girls avoid smoking. METHODS: A grounded theory approach was used to direct the discovery of process(es) that nonsmoking females undertake to remain nonsmokers. Seventeen nonsmoking females between the ages of 13 and 17 years were interviewed using open-ended questions designed by the authors. The interviews were tape-recorded and then analyzed using the techniques described by Strauss and Corbin. RESULTS: The data revealed that the process of remaining a nonsmoker is composed of three phases: making sense of smoking, rejecting smoking, and declaring oneself to be a nonsmoker. The process of remaining a nonsmoker appears to be rooted in developing self-confidence. As girls rejected smoking, self-confidence was boosted because they learned that their choice would be accepted and their strategies were effective in rejecting smoking. CONCLUSIONS: The findings of this study offer new insights into the experiences of adolescent nonsmokers. Our assumption that there is a process that underlies remaining a nonsmoker was supported. The findings suggest that adolescents use several strategies in this process. These strategies are noteworthy because they offer those who work in the field of health promotion new insights into ways in which they might contribute to increasing the ranks of nonsmokers.     

Exposure to environmental tobacco smoke in pregnant women: the association between self-report and serum cotinine

The risk of delivering a low-birth-weight infant as the result of exposing a nonsmoking pregnant woman to environmental tobacco smoke (ETS) is not well defined. The method of ascertaining ETS exposure during pregnancy may explain the lack of consistent study findings. In a large sample of pregnant women, we compared distributions between two methods of ETS exposure: self-report and cotinine, a nicotine metabolite, from serum. At livery, subjects were asked about duration and location of exposure to ETS during their second trimester. A single cotinine measurement was assayed from serum collected at 15-19 weeks gestation (limit of detection=0.05 ng/mL). Self-reported (hours per day) ETS exposure was correlated (r=0.38) with cotinine concentration. Regression analysis revealed that while self-reported ETS was significantly associated with (log) cotinine, it did not explain a large amount of total variation. While 72% of subjects reported no exposure to ETS, almost all had measurable levels of cotinine. Studies of pregnant women based upon an hours per day ETS question have likely misclassified a sizable portion of ETS-exposed women as "unexposed." Since there is recent evidence that low levels of ETS exposure result in unfavorable pregnancy outcomes, these studies have underestimated the effect of ETS.     

Factors influencing openness to future smoking among nonsmoking adolescents

BACKGROUND: To investigate the correlates of youth tobacco use in terms of nonsmoking adolescents' openness to future smoking, a secondary analysis of the 2000 and 2004 Indiana Youth Tobacco Survey (IYTS) was conducted. METHODS: A representative sample of 1416 public high school students in grades 9-12 and 1516 public middle school students in grades 6-8 (71.44% and 72.53% response rates, respectively) were surveyed in 2000, and 3433 public high school students and 1990 public middle school students (63.04% and 65.44% response rates, respectively) were surveyed in 2004. RESULTS: Seventy-four percent of students in 2000 were not open to future smoking and 77% were not open in 2004. The adolescent cohort in 2004 became more exposed to antitobacco messages and less exposed to protobacco messages and environmental tobacco smoke (ETS) compared with their counterpart in 2000. Whereas gender, grade, race/ethnicity, and exposure to antitobacco messages were insignificant predictors for openness to future smoking, exposure to ETS either in homes or in cars was a strong predictor for openness to future smoking (the higher the exposure to ETS, the more open to future smoking) in both unadjusted and adjusted multivariate models. Exposure to protobacco messages had a greater effect on openness to future smoking than exposure to antitobacco messages. The rate of transition from openness to future smoking to tobacco use initiation is higher among white adolescents than among minority adolescents. CONCLUSIONS: More efforts should be made to reduce adolescents' exposure to ETS and protobacco messages.     

Acute exposure to environmental tobacco smoke and heart rate variability

Environmental tobacco smoke (ETS) has been associated with cardiovascular mortality. Pathophysiologic pathways leading from ETS exposure to cardiopulmonary disease are still being explored. Reduced cardiac autonomic function, as measured by heart rate variability (HRV), has been associated with cardiac vulnerability and may represent an important pathophysiologic mechanism linking ETS and risk of cardiac mortality. In this study we evaluated acute ETS exposure in a commercial airport with changes in HRV in 16 adult nonsmokers. We conducted ambulatory electrocardiographic (ECG) monitoring for 8-hr periods while participants alternated 2 hr in nonsmoking and smoking areas. Nicotine and respirable suspended particle concentrations and participants' blood oxygen saturation were also monitored. We calculated time and frequency domain measures of HRV for periods in and out of the smoking area, and we evaluated associations with ETS using comparative statistics and regression modeling. ETS exposure was negatively associated with all measures of HRV. During exposure periods, we observed an average decrement of approximately 12% in the standard deviation of all normal-to-normal heart beat intervals (an estimate of overall HRV). ETS exposures were not associated with mean heart rate or blood oxygen saturation. Altered cardiac autonomic function, assessed by decrements in HRV, is associated with acute exposure to ETS and may be part of the pathophysiologic mechanisms linking ETS exposure and increased cardiac vulnerability.     

Personal exposure to environmental tobacco smoke: salivary cotinine, airborne nicotine, and nonsmoker misclassification.

A large study was conducted to assess exposure to environmental tobacco smoke (ETS) in a geographically dispersed study population using personal breathing zone air sampling and salivary cotinine levels. Approximately 100 self-reported nonsmoking subjects in each of 16 metropolitan areas were recruited for this investigation. Cumulative distributions of salivary cotinine levels for subjects in smoking and nonsmoking homes and workplaces exhibited a general trend of decreasing salivary cotinine levels with decreasing time spent in smoking environments. Median salivary cotinine levels for the four experimental cells in the study (product of smoking and nonsmoking home and workplaces) were comparable to those reported for a large national study of serum levels of cotinine (Third National Health and Nutrition Examination Survey, NHANES III), when the latter was corrected for expected differences between serum and saliva concentrations. However, the most highly exposed group in this study had a median salivary cotinine concentration approximately a factor of 2 greater than that of the comparable group in the NHANES III study. Misclassification rates, both simple (for self-reported nonsmokers) and complex (self-reported lifetime never smokers), were near the median of those reported for other studies. Estimated misclassification rates for self-reported lifetime never-smoking females are sufficiently high (2.95% using a discrimination level of 106 ng/ml) that, if used in the Environmental Protection Agency (EPA) risk assessment related to ETS and lung cancer, would place the lower 90% confidence interval (CI) for relative risk at nearly 1.00, i.e., no statistically significant increased risk. For the 263 most highly exposed subjects in the study whose self-reported nonsmoking status was accurate, the correlation between airborne exposure to nicotine and average salivary cotinine is so small, on an individual basis, that it makes the relationship useless for estimating exposure on a quantitative basis. When subjects are grouped according to likely categories of nicotine exposure, correlation between group median airborne nicotine exposure and salivary cotinine level increases dramatically. The comparison improves for the most highly exposed subjects, suggesting that such quantitative comparisons are useful for only those subjects who are exposed to the higher levels of ETS. However, airborne nicotine exposure for most of the subjects does not account for estimated systemic levels of nicotine, based on salivary cotinine levels.     

Respiratory irritation from environmental tobacco smoke.

Acute physiological and chronic pathological responses of the respiratory tract to environmental tobacco smoke (ETS) are reviewed briefly. This study excludes discussion of the possible risk of lung cancer and the known impact of carbon monoxide on the fetus and adult. In some environments, the dose of particulate matter and the concentrations of irritant vapors absorbed on the ETS particles reach a level for which a physiological response may be expected, not only in the nose but also the bronchi. However, direct measurements indicate only small increases of nasal and bronchial resistance if normal subjects are exposed to maximal, likely concentrations of ETS. ETS is readily detected by the nonsmoker, but there is no strong evidence that pulmonary reactions have a psychogenic basis. The condition of approximately 20% of asthmatic patients is exacerbated by ETS exposure. Further study is needed to clarify the likelihood that adults will progress from a minor physiological response to pathological reactions, e.g., chronic obstructive lung disease. In young children (who are less able to escape from ETS), the association between exposure and an increase in respiratory disease is stronger than in adults. Exacerbation of asthma and an increase of respiratory disease are further arguments for legislation to guarantee smoke-free air to the nonsmoking public.     

Exposure to environmental tobacco smoke in the nonsmoking population of Cambodia

OBJECTIVE: To estimate the extent of environmental tobacco smoke (ETS) exposure among nonsmokers in the adult population of Cambodia. METHODS: A cross-sectional survey was conducted on a nationally representative sample of 13,988 Cambodian adults in 2005. Information on smoking and exposure to ETS was obtained by trained interviewers using a standard questionnaire. RESULTS: Overall, 37.4% of the 10,263 nonsmoking responders, or an estimated 1,629,700 nonsmoking Cambodians, were exposed to ETS. One third of pregnant women (31.4%) were exposed to ETS at home. In both unadjusted and adjusted models, men were less likely to be exposed to ETS at home (OR=0.34; 95% CI=0.29-0.41) and more likely to be exposed to ETS at work and in public places (OR=3.08; 95% CI=2.14-4.43 and OR=2.17; 95% CI=1.82-2.59, respectively). Education was inversely related to ETS exposure at home (OR=0.51; 95% CI=0.27-0.96 for 10 years of education vs 5 years or less). Legislators, senior officials, and managers were less likely to be exposed to ETS at home than professionals (OR=0.13; 95% CI=0.04-0.46), but more likely to be exposed at work or in public places. Rural residence was associated with higher ETS exposure in the home (OR=2.52; 95% CI=1.71-3.71) and lower ETS exposure at work (OR=0.42; 95% CI=0.24-0.76) compared to urban residence. CONCLUSIONS: The high prevalence of ETS exposure among adult Cambodians indicates an urgent need for specific measures such as public awareness campaigns, policies, and regulations to protect nonsmokers in Cambodia.     

Passive smoking in Germany and Poland: comparison of exposure levels, sources of exposure, validity, and perception.

Nonsmoking females age 35-65 years from Bremen, Germany (91 women), and Opole, Poland (98 women), were interviewed about their recent passive smoking exposure. We obtained urine samples at the time of interview and determined the concentration of cotinine as an indicator of tobacco smoke exposure. In Poland and in Germany, the vast majority of nonsmoking women are involuntarily exposed to environmental tobacco smoke (ETS). Polish women had slightly higher exposure levels than German women, with overall means of 9.93 and 8.65 ng cotinine/mg creatinine, respectively. Smoking by the husband was the major source of exposure in both study groups. In the Polish group, the work place was also an important source of ETS exposure. The validity of self-reported passive smoking exposure was found to be generally good; it was somewhat better in the German study group. A negative attitude toward tobacco smoke was slightly stronger among the German women. The percentage of women misreporting their active smoking status was low.