Global Bridges Accomplishments Since April 2011, Regional Partners have

trained over 1575 HCPs from 53 countriesOver 18000 person-hours of training, reaching thousands of patients

Presented at national, regional, and global meetings with combined attendance of over 22,000

www.globalbridges.org launched in 6 languages

724 members have joined via website

Active collaborations with ATTUD, treatobacco.net, Global Nurses Network, American Academy of Pediatrics, Global Smokefree Partnership, Hong Kong Dept of Health, INWAT, American Association of Anesthesiologists, and others

Secondhand Smoke – The Science and Big Tobacco’s Smokescreen

Richard D. Hurt MD

Professor of Medicine, College of Medicine

Director, Nicotine Dependence Center

Mayo Clinic

rhurt@mayo.edu

Objectives

• Be able to name at least 4 toxic chemicals found in secondhand smoke

• Understand that as little as 5 minutes of exposure to SHS can have an adverse effect on the arterial endothelium

• Recognize that smoke-free workplace laws reduce the rates of Acute Myocardial Infarction

• Recognize Big Tobacco’s tactic of creating doubt

Public Health Policies Cigarette Companies Hate the Most

• Increase in cigarette taxes

• Smoke-free workplace laws

• Why?

•↓ cigarette consumption in continuing smokers

• ↑ the chance of a smoker to stop

• ↓ the chance of a young person starting to smoke

…defend itself on three major fronts -- litigation, politics, and public opinion.…defend itself on three major fronts -- litigation, politics, and public opinion.

-- creating doubt about the health charge without actually denying it

-- creating doubt about the health charge without actually denying it

Lung Cancer Mortality and Smoking

CP969217-4

21,895 69,645 17,3660

10

20

30

40

8.70

15.50

32.79

Sta

nd

ard

ized

mo

rtal

ity

rate

for

lun

g c

ance

r/10

0,00

0

Hirayama T. BMJ 282:183, 1981

Population at enrollment

Non-smoker wives of non-smokerhusbandsNon-smoker wives of husbandswith smoking habitsWomen with smoking habits

Cigarettesmokers

Non-smokerFamilial passivesmoking (+)Non-smoker

Familial passivesmoking (-)

Total108,906

Dr. Adlkofer who is the Scientific Director of the German Verbandt, has committed himself to the position that Lee and Hirayama are correct and Mantel and TI are wrong.

Dr. Adlkofer who is the Scientific Director of the German Verbandt, has committed himself to the position that Lee and Hirayama are correct and Mantel and TI are wrong.

They believe Hirayama is a good scientist and that his nonsmoking wives publication was correct.

They believe Hirayama is a good scientist and that his nonsmoking wives publication was correct.

He replied with a strong statement that Hirayama was correct, that the TI knew it and that the TI published its statement about Hirayama knowing that the work was correct.

He replied with a strong statement that Hirayama was correct, that the TI knew it and that the TI published its statement about Hirayama knowing that the work was correct.

Dr. Takeshi Hirayama1923-1995

“The grandfatherof epidemiologyin Asia”- JudithMackay

Mortality in Non-Smoking Chinese WomenSecondhand Smoke

Prospective cohort of 72,829 non-smoking women

Secondhand smoke exposure from spouses, work and early life

All cause and specific cause (cancer & CVD) mortality

Smoking spouses:

1.15 ↑ all cause mortality (CI 1.01-1.31)

1.37 ↑ CVD mortality (CI 1.06-1.78)

Smoking at work:

1.79 ↑ lung cancer mortality (CI 1.09-2.93)Wen W, BMJ 333:376, 2006

California EPA Report on SHS – 2006Excess Morbidity and Mortality in USA

PregnancyLow birth weight infants

Pre Term Delivery

24,500

71,900

ChildrenAsthma Episodes 202,300

Lower Respiratory Illness 150,000 - 300,000

Otitis Media Office Visits 790,000

SIDS 430

AdultsCardiac Deaths 46,000 (22,700-69,600)

Lung Cancer Deaths 3,400

SHS and Exacerbations of Asthma in Children

• 199 children with asthma

• Parental report of ETS exposure

• Median urine cotinine 5.6, 13.1 and 55.8 with no SHS exposure, mother or other persons, mother and other persons

• acute asthma exacerbations with exposure (RR 1.8 parent report & 1.7 by cotinine)

• FEV1 with exposure

Chilmonczyk BA. NEJM 328:1665, 1993

SHS Exposure and Urine CotinineC

oti

nin

e (n

g/m

L)

Chilmonczyk BA. NEJM 328:1665, 1993

Noexposure

Mother orothers smoke

Mother andothers smoke

1

10

100

1000

5.6

13.1

55.8

CP969217-3

the rats resisted to the daily loading into the exposure tubes and continued to struggle inside the tubes right after the beginning of the exposure. By and large, the rats of the sidestream groups reacted more vigorously than those of the mainstream group.

the rats resisted to the daily loading into the exposure tubes and continued to struggle inside the tubes right after the beginning of the exposure. By and large, the rats of the sidestream groups reacted more vigorously than those of the mainstream group.

the rats of the sidestream groups continued to show shaggy fur and some pronounced respiratory symptoms characterized by whistling and rattling sounds.

the rats of the sidestream groups continued to show shaggy fur and some pronounced respiratory symptoms characterized by whistling and rattling sounds.

1 rat of the mainstream group, 9 rats of the puffed and 11 of the nonpuffed sidestream group died “spontaneously”.

1 rat of the mainstream group, 9 rats of the puffed and 11 of the nonpuffed sidestream group died “spontaneously”.The rats of the sham and the cage control groups increased their body weight during the 21 days of exposure

The rats of the sham and the cage control groups increased their body weight during the 21 days of exposure

The sidestream groups showed a decrease to approx. 80 percent of their initial body weight.The sidestream groups showed a decrease to approx. 80 percent of their initial body weight.

SOURCE: Pechacek & Babb, British Medical Journal, 2004.Pechacek TF & Babb S. BMJ 328:980-3, 2004.

PubMed Central PMCID: PMC404492

Tobacco Smoke & Cardiovascular RiskNon-linear Dose Response

Brief SHS Exposure and Aortic Function

• 16 male nonsmokers and 32 smokers (active or sham smoking) undergoing cardiac catheterization for chest pain

• Aortic catheter to measure pressure and diameter

• SHS exposure x 5 minutes vs. 1 cigarette vs. sham smoking

• aortic distensibility of 21%, 27% and 0%

Stefanadis C. Ann Intern Med 128:426, 1998

SHS and Coronary CirculationAcute Effects

• Healthy smokers (n=15) and nonsmokers (n=15)

• Coronary flow velocity reserve measures by transthoracic doppler echocardiography

• Baseline and hyperemic (IV adenosine triphosphatae) phases

• 30 minute SHS exposure in hospital smoking room

• Abrupt reduction in coronary flow velocity reserve in nonsmokers

Otsuka, R. JAMA 286:436-441, 2001

SHS and Coronary Heart Disease

• 4729 men age 40-59 followed for 20 years• Baseline tobacco use status and serum

cotinine• Nonsmokers classified as light SHS exposure

(0.7 ng/ml) or heavy SHS exposure (0.8-14.0 ng/ml)

• hazard ratios for heavy SHS exposure especially in first (3.73; CI 1.32-10.58) and second (1.95; CI 1.09-3.48) 5 year follow-up

• Risk of CHD among heavy SHS exposure similar to light smokers (1-9 cpd)

Whincup PH, et al. BMJ, doi:10.1136/bmj.38146.427188.55 (published 30 June 2004)

Whincup PH, et al. BMJ, doi:10.1136/bmj.38146.427188.55 (published 30 June 2004)

1992 U.S. EPA Report

• SHS is a Group A carcinogen (arsenic, asbestos, benzene, radon, vinyl chloride)

• 3,000 lung cancer deaths/year in nonsmokers

• 8,000 to 26,000 new asthma cases in children

• 150,000 to 300,000 cases of bronchitis and pneumonia in toddlers

• Smoke-free work place reduces SHS exposure

Tobacco Smoke Constituents

• Arsenic

• Benzene

• Benzo[a]pyrene• Cadmium

• Chromium VI

• Cresol

• Formaldehyde• Formaldehyde

• Lead

• Nitrosamines

• Phenol

•Polycyclic aromatic hydrocarbons

• Vinyl chloride

• Polonium 210• Polonium 210Alexander Litvinenko

Nov. 22, 2006Nov. 1, 2006

…probably the single most important challenge we currently face.…probably the single most important challenge we currently face.

This will have a very direct and major impact on consumption -- an impact which will be as bad as, or worse than, excise tax increases.

This will have a very direct and major impact on consumption -- an impact which will be as bad as, or worse than, excise tax increases.

We have been referring to our initial approach as “sand in the gears.” Our objective was to slow down the ETS risk assessment until we could get broader policy declarations out of the Administration. To be honest, we made every effort to prevent the Risk Assessment.

We have been referring to our initial approach as “sand in the gears.” Our objective was to slow down the ETS risk assessment until we could get broader policy declarations out of the Administration. To be honest, we made every effort to prevent the Risk Assessment.

Senator Helms further complained about Secretary Sullivan’s statements… This position was further strengthened by a Howard Baker to Sununu call indicating that Sununu was understanding of our situation.

Senator Helms further complained about Secretary Sullivan’s statements… This position was further strengthened by a Howard Baker to Sununu call indicating that Sununu was understanding of our situation.

Howard H. Baker, Jr.

• Senator from Tennessee 1967- 85

• Chief of Staff in the Reagan White House 1987-88.

• Former Chair of the Board of Trustees, Mayo Foundation.• Ambassador to Japan 2001-05• Baker, Donelson et al

received$2.6M from cigarette companies in 1998 alone.

Science for Hire

• Smoke-free indoor air policies cigarette consumption

• Global ETS consultant program intended to influence public opinion on secondhand smoke

• Program run by U.S. lawyers because they “…have expertise in both scientific and public affairs arenas.”

• Consultants wrote articles and books for scientific and lay press, presented at conferences, lobbied political figures, testified before legislative bodies

Muggli ME, et al. Nicotine Tob Res 5:303-314, 2003

ETS Consultants Program

1987 U.S.

1988 Europe – France, Germany, Italy, Norway, Spain, Sweden, UK

1989 Asia/Pacific – Australia, Hong Kong, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, Thailand

1991 Latin America – Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, Venezuela

Muggli ME, et al. Nicotine Tob Res 5:303-314, 2003

Hong Kong Dr John Bacon-Shone, Department of Statistics, University of Hong Kong,

Biostatistics/environmental epidemiologyDr Linda Koo, Department of Community Medicine, University of Hong Kong, Scientist/ETS EpidemiologyDr Sarah Liao, EHS Consultants Ltd, Occupational healthDr Alun McIntyre†, Director, Consultants in Environmental Sciences (Asia) Environmental scienceDr Clive Ogle, Department of Pharmacy, University of Hong Kong, Pharmacology

Assunta M, Fields N, Knight J, Chapman S. Tobacco Control. 2004;13(Suppl 2):ii4-12

In a series of scientific articles, Dr. Koo has reported that diet, independent of exposure to ETS, appears to be associated with the relatively high incidence of lung cancer among non-smoking Chinese women in Hong Kong.

In particular, Dr. Koo reported that vegetables, meats and fish that are smoked, salted, cured or pickled are associated with an increased lung cancer risk while fresh versions of those foods are not.

No significant association was reported in Dr. Koo’sinvestigations between ETS and lung cancer.

Spring O’Brien and the Euro Center Communications Group have been asked to put forward public relations proposals for an important campaign in two categories of the country:

Spring O’Brien and the Euro Center Communications Group have been asked to put forward public relations proposals for an important campaign in two categories of the country:

Primary Countries(in which researchis being conductedand PR is required)

Primary Countries(in which researchis being conductedand PR is required)

FranceGermanyItalyPortugalSpainSweden

FranceGermanyItalyPortugalSpainSweden

1.2 The “passive smoking” debate

For the last 15 years since the anti-smoking lobby created the ETS issue, it has increasingly tried to focus on the ‘passive’ smoker rather than the active smoker.

1.2 The “passive smoking” debate

For the last 15 years since the anti-smoking lobby created the ETS issue, it has increasingly tried to focus on the ‘passive’ smoker rather than the active smoker.

1.3 A new test method changes the debate1.3 A new test method changes the debate

In 1994, a respected research centre, Hazleton Europe, tested 225 people in Northern England. Subjects wore a personal sampler for 24 hours which precisely measured the amount of exposure to tobacco smoke.

In 1994, a respected research centre, Hazleton Europe, tested 225 people in Northern England. Subjects wore a personal sampler for 24 hours which precisely measured the amount of exposure to tobacco smoke.

This test demonstrated that the actual levels of ETS are minimal.This test demonstrated that the actual levels of ETS are minimal.This resulted in a surprisingly favourable reaction in the media in many countries.This resulted in a surprisingly favourable reaction in the media in many countries.

4.5.2 Objectives: Spain4.5.2 Objectives: Spain

• Demonstrate the superiority of the more scientific methods used by the Hazleton study over epidemiology studies.

• Demonstrate the superiority of the more scientific methods used by the Hazleton study over epidemiology studies.

• Create media interest in the Hazleton study not only for the findings but also for the method itself.

• Create media interest in the Hazleton study not only for the findings but also for the method itself.

4. WINNING INFLUENCE4. WINNING INFLUENCE

• Build regular contact with priority opinion leaders in government, politics, media and the business community.

• Build regular contact with priority opinion leaders in government, politics, media and the business community.

• The need to build good relations with key media contacts is of prime importance.

• The need to build good relations with key media contacts is of prime importance.

5. RESOCIALIZATION OF SMOKING5. RESOCIALIZATION OF SMOKING

• To develop and exploit relevant BAT initiatives and core materials on resocialization of smoking. We must promote the cause of sound science in terms of smoking issues and assure that fair regulatory regimes are established to provide for consumer freedom.

• To develop and exploit relevant BAT initiatives and core materials on resocialization of smoking. We must promote the cause of sound science in terms of smoking issues and assure that fair regulatory regimes are established to provide for consumer freedom.

The Latin Project

• Financed by BAT (60%) and Philip Morris (40%) and administered by Covington & Burling

• 1994 Total Budget $680,000: $210,000 for retainer agreements with “consultants”

• 13 “consultants” from Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, and Venezuela

Barnoya J. Tob Control; 11:305-314, 2002

Chilean Consultants to the Latin Project

Barnoya J. Tob Control; 11:305-314, 2002

Name Affiliation Activities

Dr. Hector Croxatto Catholic University of Chile

Initial Training Session

Dr. Lionel Gil (toxicologist)

University of Chile Medical School

Influence of outdoor pollution on IAQ paper published

Guillermo Guesse (architect)

Unknown Unknown

Dr. Ricardo Katz UnknownMonitor government activities on IAQ regulations

Dr. Sergio Tezanos-Pinto University of Valparaiso Initial Training Session

(C) Chile

(i) Retainer relationships. Retainer agreements are proposed for Drs. Gil and Lopez……Dr. Gil would be expected to:

(a) Respond promptly to media articles misrepresenting the science of ETS or calling for smoking restrictions for scientifically unjustified reasons.

(b) Prepare and place two popular articles discussing indoor air quality concerns.

….to make scientific presentations in opposition to such legislation.

Budget: $20,000

ETS Consultants ProgramArgentina

• 1992 – Parliament passed strong legislation to restrict smoking in public places

• Industry mounted massive public opinion campaign to encourage President Carlos Menem to veto the legislation

• Dr. Carlos Alvarez – Personal Scientific and Technical Advisor to President Menem

• Dr. Alvarez – Cardiologist, Professor of Medicine, and Head of Instituto de las Clinicas Cardiovasculares

The reports we have received indicate that Dr. Carlos Alvarez played a very useful role in the larger industry efforts to defeat, and then to convince President Menem to veto, the antitobacco legislation approved by the Argentine Parliament at the end of 1992.

The reports we have received indicate that Dr. Carlos Alvarez played a very useful role in the larger industry efforts to defeat, and then to convince President Menem to veto, the antitobacco legislation approved by the Argentine Parliament at the end of 1992.

Dr. Alvarez’s activities included conversations with Senators from both parties and a series of conversations with President Menem as well as President Menem’s brother, who serves as President of the Argentine Senate.

Dr. Alvarez’s activities included conversations with Senators from both parties and a series of conversations with President Menem as well as President Menem’s brother, who serves as President of the Argentine Senate.Dr. Alvarez also provided President Menem with a briefing package and covering letter that pointed out that the smoking restrictions that had been proposed lacked a solid scientific basis.

Dr. Alvarez also provided President Menem with a briefing package and covering letter that pointed out that the smoking restrictions that had been proposed lacked a solid scientific basis.

…Dr. Alvarez expects to be paid for his efforts in connection with the Argentine antismoking legislation.

…Dr. Alvarez expects to be paid for his efforts in connection with the Argentine antismoking legislation.…his assumption is that the industry expects to compensate him for his efforts, which he believes to have been of decisive importance.

…his assumption is that the industry expects to compensate him for his efforts, which he believes to have been of decisive importance.

Smoke-Free Ordinances and Heart Attacks

• Helena, MT: Monthly admissions for AMI ↓ 40 → 16 (CI -31.7 to -0.3)

Sargent, RP. BMJ 328:977, 2004.

• Pueblo & El Paso, CO: ↓ Admissions for AMI in Pueblo 257/100,000 person years → 187 vs. El Paso 119 → 116. (Post to Pre RR 0.73 vs. 0.97)

Bartecchi, C. Circualtion. 114:1490, 2006.

• Scotland : 19% ↓ Admissions for troponin confirmed Acute Coronary Syndrome

Pell JP, et al NEJM 359:482, 2008

• Bowling Green & Kent, OH: 47% ↓ Admissions for CHD 3 years after ordinance

• Khuder ,SA. Prev Med 45:3,2007

AMI Counts Per 100,000 Person Years

Bartecchi, C. Circualtion. 114:1490, 2006.

©2011 MFMER | 3152300-45

To evaluate the population impact ofsmoke-free laws on the incidence of Myocardial Infarction (MI) and Sudden Cardiac Death (SCD) in Olmsted County during the 18-month calendar period before and after implementation of eachsmoke-free ordinance

Smoke-free Laws and Cardiovascular Events in Olmsted County MN

Hurt RD et al Arch Int Med 172:1635, 2012Funded by Clearway Minnesota and NIH (R01 HL59205, R01 AG034676)

©2011 MFMER | 3152300-46

The Rochester Epidemiology Project (REP)

• Medical records linkage system

• Links and archives medical records of virtually all persons residing in Olmsted County, Minnesota

• Identifies patients through their outpatient (office, urgent care, or emergency department) and hospital contacts across all local medical providers

Incidence Rates and Relative Risks of MI and SCD 18 Months Pre- and Post-

Smoke-free LawsMI Incidence Rate comparisons

Age & Sex-Adjusted Rate per 100,000 (95% CI)

Prior Post

Adjusted HR (95% CI), P

Pre-Ordinance # 1 vs Post-Ordinance #2 n = 187 150.8 (129.0-172.6) n = 139 100.7 (83.8-117.5) 0.67 (0.53-0.83), <0.01

SCD Incidence Rate comparisons

Age & Sex-Adjusted Rate per 100,000 (95% CI)

Prior Post

Adjusted HR (95% CI), P

Pre-Ordinance # 1 vs Post-Ordinance #2 n = 143 109.1 (91.0-127.2) n = 133 92.0 (75.7-108.3) 0.83 (0.65-1.06), 0.13

*Adjusted for age and sex

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

10

20

30

4019

99

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

2

4

6

8

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

5

10

15

20

25

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

0

10

20

30

Prevalence of Self-Reported High Cholesterol, Diabetes, Hypertension and Obesity in Minnesota, 1999-2010 from

the Behavioral Risk Factors Surveillance System (BRFSS)

Pre

vale

nce

(%)

Pre

vale

nce

(%)

High Cholesterol Hypertension

Pre

vale

nce

(%)

Pre

vale

nce

(%)

Diabetes Obesity (BMI 30 kg/m2)

Prevalence of Self-Reported Current Smokingin Minnesota, 1999-2010 from Behavioral

Risk Factors Surveillance System (BRFSS)

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

5

10

15

20

25

Year

Pre

vale

nce

(%

)

Current Smokers

Conclusions• The implementation of smoke-free ordinances

was associated with 33% decrease (p< 0.01) in MI and 17% decrease (p= 0.13) in SCD

• The magnitude is not explained by secular trends, community concurrent interventions or changes in known cardiovascular risk factors

• SHS exposure should be considered a modifiable risk factor for MI and SCD

• All people should avoid SHS exposure but people with known CV disease should have NO exposure to SHS

Smoke-free Laws and Reduced AMIHow Could This Be True ?

• Non-linear dose response to SHS

• People with pre-existing CAD

• SHS → ↑platelet adhesiveness

• SHS → Endothelial dysfunction → arterial dilatation

• SHS → Coronary velocity reserve

Juster HR, et al, Am J Public Health 97:2035, 2007

We do know that choice and accommodation with regard to smoking are two powerful and positive positions. And, our spokesmen cannot utter those two words enough.

We do know that choice and accommodation with regard to smoking are two powerful and positive positions. And, our spokesmen cannot utter those two words enough.

Smoke-Free OrdinancesRestaurant and Bar Revenues

• Sales tax data• 15 cities with smoke-free restaurants• 5 cities and 2 counties with smoke-free bars• Matched comparison cities and counties with no

restrictions• No significant difference in total retail sales in

eating and drinking places or on ratio between sales in comparison communities

• Smoke-free bar ordinances had no significant effect on fraction of revenues going to eating and drinking places that serve liquor

Glantz SA. Am J Pub Health 87:1687-1693, 1997

Also, the economic arguments often used by the industry to scare off smoking ban activity were no longer working, if indeed they ever did. These arguments simply had no credibility with the public, which isn’t surprising when you consider that our dire predictions in the past rarely came true.

Also, the economic arguments often used by the industry to scare off smoking ban activity were no longer working, if indeed they ever did. These arguments simply had no credibility with the public, which isn’t surprising when you consider that our dire predictions in the past rarely came true.

U.S. Surgeon General Report 20066 Key Findings

• Detectable cotinine concentrations in 88% of non-smokers (1988) → 43% (2002)

• Secondhand smoke causes disease and premature death in children and adults

• ↑ risk of SIDS, acute respiratory infections, ear infections and more severe asthma in exposed children

www.surgeongeneral.gov/library/secondhandsmoke

U.S. Surgeon General Report 20066 Key Findings (cont.)

• Immediate adverse effects on C.V. system in exposed adults and causes heart disease and lung cancer

• No risk-free level of exposure

• Eliminating smoking indoors protects non-smokers but ventilation and/or separation do not.

www.surgeongeneral.gov/library/secondhandsmoke

2006 U.S. Surgeon General Report Cigarette Company Response

Philip Morris- “We are studying the report.”

R.J. Reynolds- “…..does not change our views about secondhand smoke.”

“There are still legitimate scientific questions concerning the reported risks of secondhand smoke.”

“People who don’t want to work around it don’t have to work at that establishment”

“Public promises were intended to deceive the American public into believing that there was no risk associated with passive smoking and that Defendants would fund objective research to find definitive answers. Instead, over the decades that followed, Defendants took steps to undermine independent research, to fund research designed and controlled to generate industry favorable results, and to suppress adverse research results”

United States et.al. v. Philip Morris et. al. (2006)

Racketeers

Honorable Gladys Kessler, United States District Court for the District of Columbia

We owe it to our grandchildren

December 2007

September 2009

No matter how innocent they appear, the tobacco industry CANNOT BE TRUSTED!

63 Y/O Male Physician

• Stopped smoking over 30 years ago(1975).

• Strong family history of CAD.

• Asymptomatic.

• Regular exercise echo because of family history.

• Positive exercise test led to coronary angiogram.

63 Y/O Male Physician

How do you advise the patient about eating in a restaurant or bar where smoking is allowed?

A. It isn’t a big deal. Not to worry.

B. If you start having chest pain take an aspirin.

C. Best to completely avoid secondhand smoke exposure.

D. Eat at home or at MacDonald’s where it is smoke-free.

63 Y/O Male Physician

• There was significant 3 vessel disease- RCA, circumflex, and 1st diagonal.

• CABG vs angioplasty and stents.• Successful angioplasty and 7 drug

eluting stents placed.• Dismissed on Plavix, ASA, Celebrex,

simvastatin.• Total cost $85,000.

63 Y/O Male Physician

Now what do you tell the patient about eating in a restaurant or bar where smoking is allowed?

A. You are fixed. Not to worry.B. Make sure you do not forget to take your

Plavix and ASA. Wouldn’t want your platelets to aggregate.

C. Eat at MacDonald’s. It is smoke-free and not to worry about Big Mac’s or french fries. You are fixed.

D. Urge your city council to make all work places smoke-free