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Identifying the Prevalence of Smoking and Second-Hand Smoke Leading to the

Development of Lung Cancer in Adulthood

Nathaniel Goleno, NaKeisha Kelley, Dakota Luknis, Jeremy Ray, Tara Williams

Centofanti School of Nursing, Youngstown State University

NURS 3749: Nursing Research

Ms. Randi Heasley

April 5, 2023
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Introduction

Young adulthood, the time when one is exposed to new people, new experiences, and

new behaviors. One of these behaviors is smoking as claimed, “Opportunities frequently arise

during adolescence to initiate or engage in risk-taking behaviors, some of which may be

biologically driven, that would not be sanctioned by parents/guardians/other adults (Wiener, et

al, 2020).” Tobacco use in adolescence often leads to continuation in adulthood. This precedes to

be a public health challenge globally among those ages 12-18 and impacts the lives of smokers

and non-smokers. With physical and environmental causes like peer pressure and secondhand

smoke, there is research and studies done that show there is an increased risk of lung cancer.

Unfortunately, we all know someone who has been negatively affected by lung cancer. To

decrease the possibility of developing lung cancer, we need to accurately assess precipitating risk

factors between smoking and secondhand smoke. In researching information on smoking and

secondhand smoke, our purpose is to seek what are the contributing factors that lead to lung

cancer and what decreases the likelihood of it developing during the adult stage of life.

Search Strategies

We used EBSCO and PubMed databases through the Maag library website to search for

peer-reviewed literature based on our PICOT question. We used the search terms “smoking”

“second-hand smoke” and “adolescents and smoking”. We also used the terms “risk and lung

cancer” for later searches. We further refined the search and used articles that were 5 years old,

or less, because we wanted to have the most accurate information available. The databases we

used for this paper are the Cumulative Index to Nursing and Allied Health Literature (CINAHL)

and MedLine. This left us with about 100 peer-reviewed articles to choose from, all of which

were written in English.

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Critical Period for Lung Cancer Susceptibility in Adolescents

Smoking cigarettes and the use of tobacco has been and continues to be a major health

problem among adolescents in the United States. An article by Wiencke, J. K. & Kelsey, K. T.

(2002), claims the percentage of high school students who participated in smoking rose by

almost one-third between 1991 and 1997. This also states in a 3-year study, 217 U.S children

tried smoking from 5th to 7th grade. 90 of them began in 5th or 6th grade and stopped by 7th, while

around 64 of them started in the 7th grade (Wiencke & Kelsey, 2002). This survey led to studies

that suspect early smoking is related to genetic alterations of lung epithelium tissue that increase

the risk of developing lung cancer later in life. There is a continuous period of lung growth from

birth to 11-12 years old being the start of puberty and ending around the age of 18 where it peaks

for females and at 24 for males. As stated by Wiencke & Kelsey (2002, p.555), “The linear phase

of lung volume is approximately 1 year shorter in males who smoke compared with those who

never smoked and 2-3 years shorter in female smokers.” Being exposed to smoke and tobacco

products before the age of 18 decelerates the growth rate and volume of the lungs and

exacerbates cell proliferation leading to “cancerization of cellular fields.”

Being compared with normal lung cells, cells of lung cancer appeared altered. There are

somatically reformed cells that are related to tobacco-damaging DNA mutations in those who

began to smoke during the adolescent stage. Wiencke and Kelsey (2002, p.556), state “Most

significantly, younger ages of smoking initiation were associated with a higher prevalence of

chromosomal deletions within the specific genomic region implicated in field cancerization in

the lung (i.e., 3p21).” 3p21 is a chromosome that is commonly found in the loss of DNA

sequences in smokers’ lungs. The deletion of this chromosome was commonly found in people

with lung cancer who claimed to have smoked before the age of 16. This is a critical period for

the lungs as it is known as the end of the Tanner pubertal stage, where girls and boys are
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reaching their maximal growth period (Wiencke & Kelsey 2002). Being exposed to carcinogens

at this time enhances the probability of malignancy in the lung tissue creating a crucial period of

susceptibility which is why it is important to identify the risks that precede this.

Second-Hand Smoke and the Prevalence

Currently, there are approximately 1.5 billion tobacco users worldwide as of 2020

according to the World Health Organization and each one could be damaging the health of those

around him or her through second-hand smoke. Second-hand smoke is defined as smoke inhaled

involuntarily from tobacco being smoked by others. In other words, you are breathing in smoke

from the smokers around and it’s entering your body as well. This looks at the commonness of

developing lung cancer in individuals who began smoking as an adolescent and compares those

to adolescents that were only exposed to second-hand smoke.

Some studies support the claim that second-hand smoke caused cardiovascular and

respiratory problems that can lead to diseases or even death in non-smoking adolescents who are

exposed to second-hand smoke. There are countries throughout the world where smoking is more

prevalent, leading to second-hand smoke being more of a concern for their leadership. One of

these countries is Estonia. In the 1990s, their leaders began to become stricter on tobacco

legislation and changed the prevalence of second-hand smoking in their country. From 2004 to

2016 the daily smokers count decreased from 48% to 31% in men and women 21% to 16%

(Relie & Rainer, 2016, p.773). The data from the study also supports that someone’s

socioeconomic status can play a determining factor in a person being exposed to second-hand

smoke. The disadvantaged have a higher risk for second-hand smoke in the home and as well in

the workplace. Over the 20-year trend study, you see the second-hand smoke prevalence decline

consistently. At the beginning of the study in 1996 that data shows that about 56% of non-
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smoking men and 43% of non-smoking women reported second-hand smoke exposure. That

number began to decline for men by 3.5 times and for women 5 times by 2016. The annual

percentage change was -6.3% per year for men and -5.5% per year for women (Relie & Rainer,

2016, p.774). This study showed that in a country with a higher-than-average smoking rate for

their population second-hand smoke was highly reported by non-smokers. Their leadership can

better control the prevalence and effects of second-hand smokers by getting the overall number

of active smokers down and cutting it off at the source. In turn, it significantly reduces the risk of

developing respiratory or cardiovascular disease in the future.

When looking at the risk of smokers transmitting their toxins to the non-smokers around

them, there is the variable of the smoker’s knowledge, actions cause, and willingness to change

their habits. According to the European Union, there are no regulations in place to protect non-

smokers in private cars. In Europe, there’s support for legislation for smoke-free cars carrying

pre-school-age children and cars that have a non-smoking person as a passenger. Second-hand

smoke is one of the most widespread air toxins when indoors. A small amount of exposure can

cause a bigger problem later in life. There is no safe level of exposure when it comes to second-

hand smoke. Cars are extremely dangerous when talking about the likelihood of exposure to

second-hand smoke due to the small volume of space and lack of fresh air being cycled through

the car. In 2017 in these EU countries there were 1.2 million deaths caused by second-hand

smoke exposure and over 60,000 of those deaths were children under the age of 11 years old

(Nogueria & Sarah, 2020, p.108). The smoking community overwhelmingly supports legislation

for a smoke-free car with pre-school-age children riding it in with an overall percentage of 93.8.

The support was high in all countries with all of them coming in at over 90% in favor and over

85% in favor when a non-smoking adult is in the car. (Nogueria & Sarah, 2020, p.110). Most
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smokers go out of their way to avoid smoking around those who do not smoke or around

children. This data is shown across all demographics. Second-hand smoke causes toxic

carcinogens in the air for anyone, especially children. Trends in recent history have shown that

exposure rates have slowed down. This will help prevent children from developing health

problems later in their life.

Never-smokers and their inherent Risk of Cancer

“Cancer is the leading cause of death among children worldwide, it represents a heavy

burden as it is not easily predictable, and its incidence is continuously rising.” An excerpt from

Parental Smoking Behavior and Childhood Cancer: A case-control study (Alyahya et al., 2020

p.572), a research study that looks at the relationship between parental smoking and their

children developing cancer. As you can imagine, smoking is the leading cause of cancer in the

world. This directly correlates with the chance of childhood cancer increasing due to the

different ways a child can be exposed. Researchers Mohammad S. Alyahya, Nihaya A. Al-

Sheyab, and Batool Amro look at the relationship between parental cigarette smoking, waterpipe

smoking, “dual smoking” (smoking both cigarettes and a water pipe) and whether that influences

the development of childhood cancer. The researchers state that when a child is diagnosed with

cancer at an early age, it suggests that there is parenteral preconception and fetal exposure to

carcinogens from smoking tobacco (Alyahya et al., 2020). However, parenteral exposure isn’t

the only way that the child’s risk of developing cancer can be increased. Second-hand smoke

exposure is just as harmful in increasing the child’s risk of developing cancer. By looking at and

interpreting this research, we need to realize how important it is to 1) prevent people from

starting to smoke, 2) get current smokers to stop smoking and 3) if you are going to smoke, do it

in a private, well-ventilated area where you aren’t going to expose children to the second-hand
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smoke. In this article, the authors state “Paternal smoking also is known to affect sperm

morphology, motility, and concentration, as well as increasing the oxidative damage to sperm

DNA.” (Alyahya et al., 2020 p.572) The nursing intervention of patient teaching is going to play

a strong role with these patients. It is important to teach males, who are trying to have a child,

that they should stop smoking so there is less of a chance of damaging their DNA. Additionally,

showing new parents the data on children’s exposure to second-hand smoke should make a huge

difference in when and where they smoke.

“The evidence on the carcinogenicity of tobacco smoking has grown vastly since the

reports of an association between cigarette smoking and carcinoma of the lung in 1950.” (Cao et

al., 2018 p.708). However, the lungs are not the only body organ that is affected by the harmful

carcinogens from cigarette smoke. The authors of Cancers Attributable to tobacco smoking in

France in 2015, reference 19 other body systems that could potentially be genetically altered by

cancer-causing agents found in cigarettes (Cao et al., 2018). It is also important to note that not

only is smoking unfavorable, but if done around others, it can be equally harmful to them as

well. “Exposure to second-hand smoke has also been found to increase the risk of lung cancer in

never smokers and has been classified as carcinogenic” (Cao et al., 2018 p.708). Because they

are still inhaling second-hand smoke, their body is ingesting harmful toxins that increase the risk

of altering DNA and causing cancer. There are people in this world, especially kids, that have

never smoked in their life and have a higher risk of developing lung cancer simply because they

were around someone who was smoking. This article, Cancer’s Attributable to tobacco smoking

in France in 2015, is looking at the data on smokers in France and looking at the number of

people who are exposed to second-hand smoke, and the incidence of lung cancer within the two

groups. The researchers found that “Tobacco smoking is responsible for a significant number of
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potentially avoidable cancer cases in France in 2015. More effective tobacco control programs

are critical to reducing this cancer burden.” (Cao et al., 2018 p.707). France’s public health

authority wanted to try and curve this number, so they launched a national programme of tobacco

control in 2019. Their goal was to reduce the number of “daily smokers” by 10% (Cao et al.,

2018 p.708). If we want the number of avoidable cancer cases to trend downward, we need to

adopt more of these national tobacco control programs worldwide.

Risk of Harm Due to Smoking During Adolescence; The Role of Extracurriculars

In adolescence, girls and boys are at the stage of indulging in risky behaviors while trying

to seek independence. Their actions may stem from the separation of family, coming into

adulthood, or developing romantic relations (Wiener, et al., 2020). Some of these risk-taking

behaviors include using tobacco products and alcohol. Research has shown that the likelihood of

this activity increases with peer pressure. “There are numerous negative health consequences

associated with tobacco use, including smoking-related cancers, cardiovascular and metabolic

diseases, pulmonary disease and conditions associated with negative pregnancy and childbirth

outcomes” (Wiener, et al., 2020, p.48). In addition to developing lung cancer from smoking,

secondhand smoke and fires are included as contributing factors. Adolescence is a critical time to

address the issue of tobacco use and ways to reduce the use of it while they are in school. In

addition to developing lung cancer from smoking, secondhand smoke and fires are included as

contributing factors. Adolescence is a critical time to address the issue of tobacco use and ways

to reduce the use of it while they are in school.

Many teenagers in high school are involved in extracurricular activities such as football,

soccer, band, student government, or clubs that have adult leaders and supervisors. Numerous

studies were done assessing the relationship between unhealthy substance abuse where “some
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researchers identified a lower use of cigarettes in adolescents involved in sports as compared

with adolescents who were not involved with sports” (Wiener, et.al, 2020, p.50). The Health

Belief Theoretical Model shows the likelihood of adolescents adopting healthy behaviors is

influenced by the demographic and socio-physiological variables around them. A study was done

by the West Virginia University Institutional Review Board, a survey through the 2017 “National

Survey on Drug Use and Health Center for Behavioral Health Statistics and Quality”, on U.S.

children 12 to 18 years old, asking about tobacco and alcohol use through an in-person interview.

The primary independent variable is school-based extracurricular activities. Looking at results

according to Wiener, et al, adolescents who were not involved in school activities were shown to

be more likely to consider smoking as compared to those who are in one or more

extracurriculars. However, 17.5% of adolescents reported they did not participate in these school

events (2020). Data was collected and results were based on negative and positive responses to a

series of questions. Negative responses were grouped into never smoking and a positive response

meant the participant was identified as a current smoker within the past 30 days and a former

smoker if it was more than 30 days at the time of the survey. This article harps on the idea of

improving health insurance to expand access to information on healthy behavior changes.

former smoker if it was more than 30 days at the time of the survey. This article harps on the

idea of improving health insurance to expand access to information on healthy behavior changes.

Identifying Causative Factors of Secondhand Smoke Exposure and Prevention Methods

Since secondhand smoke is such a problem something must be done about it. Certain

measures must be taken to prevent exposure to secondhand smoke. Two things that can help

prevent exposure to secondhand smoke and thereby decrease the risk of lung cancer are
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improving the family dynamic and educating those about the risks of secondhand smoke

exposure.

The family dynamic is directly linked to secondhand smoke exposure. The reason for this

is families who are more ‘tightly bound’ tend to strongly influence each other and set better

boundaries and rules than families who are not. The better the communication in the family, the

better outcome of preventing exposure. This is shown in an article done by researchers,

“Understanding the role of family dynamics, perceived norms, and lung cancer worry in

predicting second-hand smoke avoidance among high-risk lung cancer families.” In this study,

the researchers studied 52 individuals in 17 different families that were at high risk for

developing lung cancer. The individuals who were from families with a stronger family dynamic

tended to take more initiative to avoid secondhand smoke compared to families who had weaker

bonds. “Regarding family-level LC worry, the data were partially consistent with our

predictions. The more that high conformity families worried about LC, the stronger their

intentions to avoid ETS” (Manning et al, 2017, p. 1505). This claims that individuals that were in

high conformity families, or families who have a strong family dynamic, the more the families

worried about lung cancer the greater their intentions to avoid secondhand smoke were.

Therefore, the home environment is a crucial factor in being vulnerable to toxins.

Education on secondhand smoke is another keyway to prevention. The reason is to

provide education on the subject that directly correlates with an individual's understanding of

how detrimental secondhand smoke is to health. This research explains the main causes of

secondhand smoke and smoking and what can be done to prevent it. This study was done on

7,200 migrants and found that the bulk of the migrants were male and the number one factor

associated with smoking and secondhand smoke exposure was education (Zheng & Chang,
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2018). Education is an important aspect that can determine if inhaling smoke becomes a deciding

factor in becoming a smoker. This study claims that of 7,200 migrants, 95% knew the dangers of

smoking, however, those who were non-smokers and cautious about secondhand smoke

exposure tended to have more knowledge. (Zheng & Chang, 2018). These findings show an

understanding of the health effects of smoke. The results explain how paramount education is

regarding secondhand smoke exposure.

Long-Term Health and Medical Cost Impact of Smoking Prevention in Adolescence

When looking at the long-term health and medical cost that impact smoking prevention in

adolescence, studies show that individuals who have smoked or have attempted to smoke are at

higher risk and probable cause of becoming a current smoker regardless of their baseline or sex.

According to Li Yan Wang and Shannon L. Michael (2014, p.160) the statistics show:

“A hypothetical 1 percent point reduction in the prevalence of ever smoking in 24.5

million students in 7th-12th grades today could prevent 35,962 individuals from becoming a

former daily smoker and 44,318 individuals from becoming a current daily smoker at ages 24-32

years. As a result, lifetime medical care costs are estimated to decrease by $1.2 billion, and

lifetime QALYs are estimated to increase by 98,5910.” This shows that if a smoking prevention

program wants to be effective for adolescents it must go beyond reducing the smoking

prevalence in young adulthood. This can reduce daily smoking in adulthood. These smoking

plans lessen medical costs later in life.

Tobacco use is the leading cause of preventable death in the United States. Individuals

who have smoked died 10 years earlier than individuals who have not. Smoking harms vital

organs of the body such as the lungs and heart which causes many diseases, such as coronary

heart disease, stroke, and lung cancer. Statistics show that if you have smoked or have been
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exposed to second-hand smoke your chances of developing lung disease or lung cancer are

greater than if you have not smoked ever in life.

An informal school-based peer-led intervention for smoking prevention in adolescence

(ASSIST)

Using an informal school-based peer-led intervention for smoking prevention in

adolescence (ASSIST) about how tobacco and peer pressure are on the rise in adolescents in

schools across America. Tobacco use in adolescents has become a major public issue. A Global

Youth Tobacco Survey was done on adolescents in different schools and showed that 17.3% of

people ages 13-15 stated that they use tobacco products and 8.9% are current smokers. The

highest rate of smoking in America is 17.5% and in Europe, it is 17.9%. It takes a long time

for tobacco-related morbidity to develop, normally by adulthood. Nicotine addiction is at an all-

time high in adolescents. Schools are generally the most influential place to have smoking

prevention classes because studies show that there was effectiveness in school-based programs

for smoking prevention.

Peer pressure is one of the many reasons why young people start smoking. When in the

presence of peers, all it takes is one person to start smoking for the rest of the social group to

start as well. Studies show that the behavior that young individuals use is by associating with

like-minded people. Most peer-led programs use individuals of the same age group. In a

discussion of this article, Campbell et al. (2008, p.1599), claims that “Our study has shown that

the ASSIST training program was effective in the achievement of a sustained reduction in uptake

of regular smoking in adolescents for 2 years after its delivery.” In this peer-led research

program, they asked adolescents aged 12-13 a series of random questions about who in the

school they looked up to or whom they respected. Along with other questions, they were able to
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identify if adolescents were being influenced to smoke at an early age based on whom they

considered respected persons.

Conclusion

During your adolescent years, you will begin to make choices that could affect your

health and well-being for the rest of your life. The teenage years are when people begin to seek

independence. In our studies, we discovered that those who participate in school-based activities

are less likely to engage in smoking. Being a product of one’s environment influences the

decisions made in life that further impact health. The long-term effect of smoking, being

surrounded by second-hand smoke, and not taking the necessary precautions has the potential to

be detrimental. Health is one of the most important aspects of life that should be managed

carefully and taken seriously. There is no specific medication to prevent lung cancer but patient

education and identifying risk factors can decrease the chances of lung cancer progressing.
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