In 2006, the US general surgeon reported that exposure to (ETS) in early life is causal for wheezing. Although the role of ETS in asthma onset was still inconclusive. However a report by International Study of Asthma and Allergies in childhood published in 2012 suggested that the relationship is causal. Particles present in ETS are of smaller size (0.1 µm) which allows them to penetrate deeply into the lungs resulting in oxidative stress and the liberation of Oxidative Reactive Substances,

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... are among the most aggressive mechanisms for airway inflammation. There are susceptibility genes for asthma in predisposed individuals, however clinical expression might not be apparent unless there is appropriate environmental exposure such as inhalation of parental ETS by children or exposure to allergens. This exposure to ETS leads to epigenetic changes. Epigenetic changes are defined as heritable changes that affect gene expression without altering the DNA sequence. ETS seems to influence innate immunity predisposing to Th2associated respiratory diseases and increasing the risk for IgE-mediated sensitization, which could lead to the inflammatory and structural changes seen in allergic diseases, especially asthma. Exposure to water pipe ETS (locally called Narghile, Shisha, or Hookah) is to be considered especially in the Middle East. We hope the next WHO report would consider the harm of in-home environmental tobacco smoke exposure, and the need to protect the rights of children worldwide.