Secondhand Smoke (SHS):The Facts
Jonathan M. Samet, MD, MS
Institute for Global Tobacco Control
December 15, 2004
Department of Epidemiology
How Did Tobacco Use Become Epidemic?
• Tobacco smoking delivers nicotine, a potent addicting agent
• Risks for many smoking-caused diseases are not immediate
• It is produced at great profit by a powerful, multinational industry
• Advertising made tobacco smoking appealing and reached to children
• Governments seemingly profit from tobacco
Two Pandemics: Tobacco vs SARS
SARS• Sudden and
dreaded• Immediate global
response• Thousands of
cases and hundreds of deaths
• Spread by contact and travel
Tobacco• Slow and accepted• Delayed global
response• Billions of smokers and
millions of deaths• Spread by multi-
national corporations
What are the facts about secondhand smoke (SHS)?
• What is SHS? A complex mixture of gases and particles
• Is there significant exposure to SHS? Yes, exposures in homes and elsewhere are a threat to public health?
• Does SHS exposure cause adverse effects? Yes, to children and adults.
• Can SHS exposure be controlled? Yes, it can be readily controlled through bans.
• Is there controversy about SHS—effects and control? No, but maintained by the industry.
What is SHS?
The Manufactured Cigarette
Tobacco and additives
Tipping
paper
Cigarette Paper Adhesive
Plugwrap
Paper
FilterMonogram
Ink
Cigarette paper
Ventilation holes
Tobacco Smoke Terminology
• Mainstream smoke (MS): the smoke drawn through the mouthpiece of the cigarette when puffs are taken
• Sidestream smoke (SS): the smoke emitted from the smoldering cigarette between puffs
• Secondhand Smoke (SHS)
combination of SS and
exhaled MS
Sou
rce:
JM
Sam
et
Some Terminology•Active smoking•Passive smoking•Involuntary smoking
SHS or ETS•SHS preferred•ETS originated with industry
SHS OR ETS?
What is in SHS?
• SHS is a dynamic mixture, changing as it ages
• SHS contains the same gases and particles as MS
• SHS can be considered as qualitatively comparable to MS in terms of potential toxicity
What are the health effects of SHS?
• Evidence comes from knowledge of SHS components and their toxicity
• Evidence on active smoking and health provides a foundation
• Studies have assessed exposures and doses, using biomarkers
• Epidemiological studies provide direct evidence on health risks
Where does exposure to SHS take place?
How is it measured?
Source(s): Cigarettes smoked
Concentration: Level(s) of marker(s) in air
Exposure: contact with second-hand smoke, concentration by time
Dose: amount of material (smoke components) entering the body
Microenvironmental Model:
exposure depends on places where time spent
Basic Concepts
(Klepeis, 1999)
Personal Exposure to CO Across a Day
(Klepeis, 1999)
Assessing Exposure to Second-hand Smoke• Questionnaires
– sources– source strength– perceived exposure
• Direct Measurement– Biomarkers
• Indirect Assessment– Concentration measurements– Microenvironmental models
Biomarkers
Compounds measured in biological materials
For SHS, biomarkers include:
– Nicotine
– Cotinine
– Carboxyhemoglobin
– Thiocyanate
Change in median (50 percentile) level of cotinine among nonsmokers in the U.S. ages
3 and over
0.2
0.05
0
0.05
0.1
0.15
0.2ng/mL
1988-91 1999
Relative decline - greater than 75%
Source: Health and Nutrition Examination Survey (NHANES III & IV)
(Klepeis, 1999)
SHS Exposure
(Klepeis, 1999)
SHS Exposure
Surveillance Of Secondhand Tobacco Smoke In Latin America
Ana Navas AcienProject Coordinator
Institute for Global Tobacco Control (IGTC)
Johns Hopkins Bloomberg School of PH Baltimore, MD
Tobacco Control Program
Pan American Health Organization (PAHO/WHO)
Washington DC
Director: Jonathan Samet
Regional Advisor: Armando Peruga
Nicotine monitoring
• Passive sampling of vapor-phase nicotine
~ 120 monitors per country, 7-14 days
• 10% duplicates, 10% blanks (QC)
• Airborne nicotine concentration (µg/m3)
measured by gas-chromatography Gas-chromatograph
Nicotine filter
P75P50p250
4
8
12
Peru Chile Argentina Costa Rica Uruguay
N = 20 25 24 22 27
Hospitals – nicotine (µg/m3)
Restaurants
0
4
8
12
Peru Chile Argentina Costa Rica Uruguay
N = 15 13 8 15 14
Non-smoking area
AreaN p50 p75 p90 mean (SD)
49 1.58 2.55 3.98 1.89 (1.58)Smoking
Non-smoking 16 0.67 0.99 2.41 1.45 (3.20)
P75P50p25
4
8
12
Peru Chile Argentina Costa Rica Uruguay
N = 19 20 16 18 21
0
City Government Buildings – nicotine (µg/m3)
What are the health effects of SHS
exposure?
BMJ 1981 Jan 17;282(6259):183-5
Hirayama’s Pioneering 1981 Paper: SHS and Lung Cancer in Japanese Women
Lung Cancer Mortality in Women According to the Presence or Absence of Direct and Familial Indirect
Smoking
Source: Hirayama 1981
1986 Surgeon General’s Report
C. Everett Koop, M.D.Former U.S. Surgeon General
0.1
1
10
SHS and Lung Cancer:Meta-analysis of Female Data
RR (95% CI) in lifelong nonsmokers – smoking vs nonsmoking spouse
Source:Hackshaw et al. BMJ 315:980-88; 1997.
Rel
ativ
e ri
sk
1986: Three Key Reports
1992 EPA Risk Assessment
• Based on meta-analysis of 31 studies
• Extensively criticized by the tobacco industry
• Federal court decision• around methods• Policy implications key
•Involuntary smoking (exposure to secondhand or 'environmental' tobacco smoke) is carcinogenic to humans (Group 1).
IARC 2002
Adverse Effects of Exposure to Secondhand Tobacco Smoke
Children
Adults
Can Exposures to SHS be Reduced?
Control source- Reduce smoking
Change the source
Separate smokers and nonsmokers
Increase ventilation
Use air cleaning
Reducing Exposure to SHS
The Mass-Balance Model
Concentration of SHS depends on:
• Strength of source– Number of smokers and smoking pattern
– Emissions from cigarettes
• Ventilation– Rate of exchange of outdoor with indoor air
• Air cleaning
What works?
Elimination of the source
What does not work?
•Separation of smokers and non-smokers in the same space
•Ventilation
•Air cleaning
ASHRAE-62“This standard is under continuous maintenance by a Standing Standard Project Committee (SSPC) for which the Standards Committee has established a documented program for regular publication of addenda or revisions, including procedures for timely, documented, consensus action on requests for change to any part of standard.”
FOR IMMEDIATE RELEASE
JT to Accelerate Expansion of“Reduced Odor Cigarette Segment"
Tokyo, October 6, 2003 --- Japan Tobacco Inc. (JT) (TSE:2914) announced today an initiative aimed at the "reduced odor cigarette segment" through the launch of "Mild Seven Prime Super Lights Box" (Mild Seven Prime / JPY 300 per pack) and a sales area expansion of "Lucia Citrus Fresh Menthol" (Lucia / JPY 300 per pack), starting November 4, 2003.
In its latest medium-term management plan, JT PLAN-V, JT stated that the company is creating a new category of cigarettes with reduced tobacco odors. The creation of this new segment is part of JT's commitment to allow smokers and non-smokers to more easily coexist.
Lucia is the first product in this category, launched in the Tokyo metropolitan area, in February of this year. Following its successful market entry in Tokyo, the brand's sales area was expanded into the neighboring four prefectures in August. Since its launch, Lucia has maintained market share at levels almost twice as large as other newly marketed brands, and from November 4 onwards it will be available nationwide.
Alternative Products
Establishing Smokefree Places
• Hospitals
• Public Places
• Workplaces
• Transportation
• Restaurants
• Bars
Benefits of Smokefree Workplaces
Benefits for Employees
Creates safe and healthy workplace
Well planned and carefully implemented effort can reduce smoking among employees
Clearly defined policy leads to compliance
Benefits for Employer
Increased worker productivity
Reduces health care costs
Reduces maintenance costs
Risk of fires reduced
Worker Health and Safety• Workers exposed to SHS on the job are 34% more
likely to get lung cancer (Fontham et al 1991).
• International Labor Organization reported that cancer # 1 killer in worksite and SHS is estimated to cause 2.8% of all worksite cancers (ILO, 2002).
• Workplace smoking increases an employer’s potential legal liability
• Nonsmoking employees have received settlements in cases based on their exposure to SHS (Sweda 1997).
Change in worker protection from SHS
1986 1992-93 1995-96 1998-990
10
20
30
40
50
60
70
Percent
All estimates based on 1998-99 CPS data should be considered preliminary1986 data based on 18 years and older all others ages 15 and older
Sources: 1986 Adults Use of Tobacco Survey; all others Current Population Survey
3.0
45.8
63.068.6
Relative increase + 49.8%
Change in smoke-free workplace policy coverage among indoor American workers by type of worker
Self-respondents ages 15 years and older
53.7
27.4
34.8
71.3
44.8
50.4
76
51.4
56.8
White collar Blue collar Service 0
20
40
60
80
Percent
1992-93 1995-96 1998-99
0
10
20
30
40
50
60
70
80
90
Restaurants Hospitals Work Areas Bars SportsArenas
Malls
% S
mo
ke
rs
US minus CA
CA
16.7
42.0
58.3
78.7
31.9
54.8
6.2
10.5
47.4
58.1
37.4
57.7
Smokers’ Beliefs AboutWhere Smoking Should Never Be Allowed
Source: CPS 1995-96, 1998-99 Numbers in red are 1995-96 levels
SHS and Controversy?
Maintained Controversy about SHS Control
• Health effects• Extent of exposure• Control strategies• Costs of control measures
History of effort to protect History of effort to protect nonsmokers in U.S. from SHSnonsmokers in U.S. from SHS
1970 1975 1980 1985 1990 1995 2000
0
1
2
3
4
5Thousands
SG Jesse Steinfeld calls for nonsmokers bill of rights Jan. 1971
ICC restricts smoking to rear 20% of interstate buses.
1st report to review ETS effects
Jan. 1972
MN passes 1st lawrequiring employers to
protect nonsmokers June 1975
1st epidemiological studies published linking ETS with lung cancer Jan 1981
NAS (Nov 1986) and Surgeon General (Dec. 1986) release major reviews on health effects of ETS
Congress imposes temporary ban on smoking aboard flights of less than 2 hrs duration 1988
NCI publishes airline study demonstrates nonsmokers seated
in nonsmoking section significantly exposed to ETS Feb.
1989
Congress eliminates smoking aboard virtually all commercial airlinesFeb 1991
EPA issues major report on SHS in adults and children Jan 1993
CalEPA report links SHS to CHD & SIDS deaths in 1997
CAB requires smokingand nonsmoking seating on airlines. July 1973
Philip Morris Document (1998): Impact of smoke-free workplace policies on Cessation
Smokers facing workplace restrictions have a 84% higher quit rate than average
Anticipate a 74% increase in quitting rate if smoking was banned in all workplaces
10% industry decline if smoking was banned in all workplaces
Asia ETS Consultants
•Introduction
This note describes the status regarding attempts to consolidate a group of scientific consultants in Asia that will be willing to contribute to the debate on ETS issues. A cursory assessment of those involved is given and possible future progress with this group discussed. Recommendations regarding BAT involvement are also given.
Source: Document No. 401686705
Center for Indoor Air Research (CIAR) - Background
•The Center has an independent Science Advisory Board (SAB) which develops the research agenda for approval by the Board. The SAB recommends proposals for funding after they have been peer reviewed. Proposals can only be funded subsequent to approval by the Board. A second class of research projects-Applied Studies –are also funded if approved by the Board; such projects are not normally reviewed or recommended by the SAB.
Source: Bates No. 2021528170
“The massive effort launched across the tobacco industry against one scientific study is remarkable.”
(The Lancet 2000;355(9211):1253)
Age adjusted relative risk (95% confidence interval) for never smokers married to ever smokers compared with never smokers married to never smokers
Coronary Heart Disease:
Men: 0.94 (CI 0.85 to 1.05)
Women: 1.01 (CI 0.94 to 1.08
Lung Cancer:
Men: 0.75 (CI 0.42 to 1.35)
Women: 0.99 (CI 0.72 to 1.37)
BMJ VOLUME 326 17
MAY 2003
Philip Morris on Secondhand Smoke
Myths About SHS from the Industry
• Controversy remains about the health effects of SHS
• SHS does not contribute to IAQ problems• Smokers and nonsmokers can
“accommodate” to each other• Ventilation can control SHS exposures
• Smoking bansin hospitality venues have adverse economic consequences
What is the FCTC?
• Global evidence-based treaty designed to circumscribe the global rise and spread of the tobacco epidemic
– Addresses secondhand smoke protections, tobacco taxation, tobacco product regulation, cigarette smuggling, public education, and cessation treatment
What is the FCTC?
• First time WHO Member States have harnessed the organization’s capacity to develop a binding international convention to protect and promote global public health
• First time that low, medium, and high income countries have united to develop a collective response to chronic diseases
Continued
FCTC Final Treaty Text
• Introduction
• Objectives, guiding principles and general obligations
• Measures relating to the reduction of demand for tobacco
• Measures relating to the reduction of the supply of tobacco
• Protection of the environment
• Questions related to liability
• Scientific and technical cooperation and communication of information
Final Text: Secondhand Smoke
• Article 8
Parties recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease, disability.
Shall provide for protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places, and as appropriate, other public places.
For More Information
• http://www.jhsph.edu/IGTC/index.html• http://www.who.int/tobacco/en/• http://www.cdc.gov/tobacco/sgr/sgr_2
004/chapters.htm
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