Secondhand Smoke: An Evolution of Understanding

Sean Sharma, MD

About the Speaker

• Seeger High School• Wabash College• Indiana University School of

Medicine• Duke University Internal

Medicine & Pediatrics Residency

• St. Vincent Williamsport Hospital

Topics of Discussion

Historical Context Mechanism of Secondhand Smoke (SHS)

Damage Proven Outcomes of SHS Exposure Reaching a Solution Local Findings Statewide Efforts

Secondhand Smoke History - 1972

First Addressed in 1972 U.S. Surgeon General’s Report– “An atmosphere contaminated with tobacco

smoke can contribute to the discomfort of many individuals”

– Mention of possible harm to individuals who already have chronic heart or lung disease

History - 1975

Surgeon General’s Report 1975– Smoking is “annoying” to nonsmokers– Elevated nicotine levels in the blood of non-

smokers may possibly cause atherosclerotic disease

History – 1979 & 1982

Surgeon General’s Report – 1979– There is limited knowledge with regard to SHS, further studies

recommended

Surgeon General’s Report – 1982– Three studies completed, concern raised of link with lung

cancer in nonsmokers– “Although the currently available evidence is not sufficient to

conclude that passive or involuntary smoking causes lung cancer in nonsmokers, the evidence does raise concern about a possible serious public health problem”

History - 1984

Surgeon General Report on COPD

(Chronic Obstructive Pulmonary Disease)– Increased awareness of damage caused by

parental smoking Respiratory disease

– Short Term – Bronchitis and Pneumonia– Long Term – Decreased Pulmonary Function

Eye irritation in children

– Lung damage recognized in nonsmoking adults

History - 1986

Surgeon General’s Report – 1986– Entire report, 359 pages, dedicated to The Health

Consequences of Involuntary Smoking Conclusive evidence: Second Hand Smoke causes

Lung Cancer in nonsmokers Simply separating smokers and nonsmokers within the

same airspace does not eliminate SHS SHS exposure to children may lead to COPD in

adulthood

History - 1986

“The right of smokers to smoke ends where their behavior affects the health and well-being of

others; furthermore, it is the smokers’ responsibility to ensure that they do not

expose nonsmokers to their potential [sic] harmful effects of tobacco smoke”

- Dr. C. Everett Koop, Surgeon General

History - 1986

International Agency for Research on Cancer – World Health Organization– Passive smoking gives rise to some risk of cancer

National Research Council– Estimated increased risk of lung cancer in a

nonsmoker married to a smoker – 25%

History – 1992

EPA – SHS is a known human carcinogen– >3,000 lung cancer deaths per year in

nonsmokers attributed to SHS - 1992

History - 2005

EPA Revised Estimates in 2005– Up to 9,000 excess lung cancer deaths/year– Up to 70,000 excess heart disease deaths/year– Up to 500 SIDS deaths/year– Up to 72,000 Premature/LBW Infants per year– 200,000 episodes of childhood asthma– 300,000 cases of lower respiratory child illnesses– Nearly 1,000,000 cases of middle ear infections

History - 2006

Entire report of the Surgeon General dedicated to SHS – The Health Consequences of Involuntary Exposure to Secondhand Smoke – 727 pages

History – 2006: Major Findings

Causes premature death in nonsmoking children & adults Children exposed to SHS are at increased risk for SIDS,

acute respiratory infections, ear problems, & severe asthma

Children of smokers have slowed lung growth Exposure of adults to SHS has immediate adverse effects

on cardiac health, causing CAD & lung cancer Separating smokers and nonsmokers is not effective, only

complete elimination of smoking from indoor spaces fully protects nonsmokers

There is NO RISK-FREE LEVEL OF EXPOSURE

Present - 2011

All data relates solely to nonsmokers, and the effect of involuntary smoke exposure

Remember what we know and when we figured it out.

It is time for strong action!

Nearly a Half Century of Reports

In 1964, the Surgeon General released a landmark report that characterized the dangers of smoking as they were then understood (U.S. Department of Health, Education, and Welfare 1964).

During the intervening 45 years, 29 SGR’s have documented the overwhelming & conclusive biologic, epidemiologic, behavioral, & pharmacologic evidence that tobacco use in any form is harmful & can be deadly. The past 29 reports have established a long list of health consequences & diseases caused by tobacco use & exposure to tobacco smoke.

Mechanism

How does Smoke or Secondhand Smoke cause damage?

How Tobacco Smoke Causes Disease: The Biology & Behavioral Basis for Smoking-Attributable Disease

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Surgeon General 2010

DNA Adduct Formation – A piece of DNA that is bonded covalently to a cancer causing chemical. Genetic and epigenetic changes lead to cancer through alteration of critical cellular pathways that foster uncontrolled cell growth and defeat of normal mechanisms to restrain their growth and spread.

Endothelial Injury - Damage to the lining of coronary and peripheral arteries through an oxidative process.

Platelet Activation - Increased risk of thrombosis or clot formation blocking blood flow.

Protease/Antiprotease Imbalance - Increase destructive enzyme activity that reduces the lung’s elasticity by damaging its structure and causing emphysema.

Atherogenic Lipid Profile – Abnormal cholesterol metabolism causing an increase in triglycerides and a decrease in high-density lipoprotein cholesterol

Germ Cell Damage – Sperm and possibly eggs are damaged in smokers effecting fertility, pregnancy viability, and anomalies in offspring

Mechanism: How A Heart Attack Happens

Mechanism of Injury

Increased Stickiness of Platelets Damage Lining of Blood Vessels Decreased Coronary Flow Velocity Increase Levels of LDL “Bad Cholesterol” Dose-Response is nonlinear –

– Rapid increased risk with short term exposure– Slower further increase with longer exposure

RISK

Exposure

PROVEN OUTCOMES

Limiting Smoke Exposure Saves Lives

Pueblo Heart Study Phase I & II

Impact of Smoke-Free Ordinance in Pueblo, CO July 2003

– Rate of heart attack admissions decreased 27% in 18 months– Experimental Controls: Suburban Pueblo and Colorado Springs,

CO

Extended Analysis after Three Years– Impact not only sustained, but increased: – 41% decrease in heart attack admissions

Nine other studies have come to similar conclusions

Pueblo Heart Studies I & II

Smoke-Free laws likely reduce heart attack hospitalizations both by reducing SHS exposure, and by reducing smoking at work and at home.

Initial response– Decreased SHS

Subsequent response– Decreased smokers– Smoke-Free home rules

Amazing Factoids

More deaths are caused each year by tobacco

use than by all deaths from (HIV), illegal drug

use, alcohol use, motor vehicle injuries, suicides, and murders combined (Source: CDC)

TOBACCO USE DEATHS > Combined Deaths from HIV , Drug Use, Alcohol Use, Car Accidents, Suicides, & Murders

Leading Causes of Preventable Death

1) Tobacco Abuse– Half of all long-term smokers will eventually

die from their use of tobacco.

2) Obesity

3) Second Hand Smoke

Thirdhand Smoke

“. . . An invisible yet toxic brew of gases . . . clinging to smokers’ hair and clothing, not to mention cushions and carpeting, that lingers long after secondhand smoke has cleared from a room. The residue includes heavy metals, carcinogens, and even radioactive materials . . .”

Thirdhand Smoke

Contains at least 11 highly carcinogenic compounds

Simply closing the door, opening the window, going outside or whatever other justification that is used, is not enough

Reaching A Solution

Workplace smoking restrictions are effective Workplace restrictions lead to less smoking Smoke-free workplaces is the only effective way A majority of U.S. workers are now protected Smoke-free policies do not have any proven adverse

economic impact on industry Exposure of nonsmokers cannot be controlled by air

cleaning or mechanical air exchange Total bans on indoor smoking substantially reduce SHS

exposure even with incomplete compliance – and with full compliance risk is eliminated

Helping Smokers Quit

1-800-QUIT NOW

National Cancer Institute National Institute of Health United States Department of Health and

Human Services

1-800-QUIT NOW

When you call, a trained quit coach in your state will work with you to help you quit and avoid the things that tempt you back into the habit.– Why is Quitting Difficult?– Why do I need the Quitline?– Weight Gain Concerns?– Afraid of Failure?

1-800-QUIT NOW

Reminders are Helpful – Not Nagging It Needs to Be the Smoker’s Choice Making a Plan Increases Success Support Before, During, and After is Crucial Even a Failed Attempt is Success

http://www.becomeanex.org/

The way to quit is to re-learn everything you thought you knew about addiction and your smoking habit. And that involves taking a long, hard look at all the ways smoking has become a part of your life. You’ll pick your habit apart into little pieces you can tackle one by one. Once you begin, you’ll start to look at quitting not as one huge war, but as a series of small battles you can actually see yourself winning.

Re-learn all those things in your life that are tied to smoking.

Where Are We, Statewide?ITPC (Indiana Tobacco Prevention & Cessation)

Change the cultural perception and social acceptability of tobacco use in Indiana

Prevent initiation of tobacco use by Indiana youth Assist tobacco users in cessation Assist in reduction and protection from secondhand

smoke Support the enforcement of tobacco laws concerning

the sale of tobacco to youth and use of tobacco by youth

Eliminate minority health disparities

ITPC Survey of Rural IndianaITPC Survey Results from Four Rural Counties: •Clay, Lawrence, Montgomery, & Warren

ITPC Accomplishments: 10 Years

High School Smoking Rates Down 42% Historically Low Adult Smoking Rate 23% 30+ Smoke Free Communities 70 % of Schools Have Smoke Free Campus

ITPC: Still More to be Done

10,000 Deaths Per Year From Tobacco (State)

Nearly 8 Billion Dollars in Costs Yearly (State)

Costs of Program Covered by Master Settlement Agreement not Taxes

Local Successes

Warren County Indiana– Largest Employers Going Smoke Free– Tobacco Free County Fair– Influencing Neighboring Counties– No Town Ordinances . . . Yet

Secondhand Smoke

1972 2011

References

1) U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006.

2) U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.

3) http://www.cdc.gov/tobacco/secondhand_smoke/ 4) Rabin, Roni. A New Cigarette Hazard: ‘Third-Hand Smoke’, The New York

Times, Jan. 3, 2009.