Environmental Tobacco Smoke David McFadden MD, MPH Assistant Professor of Medicine Mayo Nicotine Dependence Center consultant

Transcription

1 Environmental Tobacco Smoke David McFadden MD, MPH Assistant Professor of Medicine Mayo Nicotine Dependence Center consultant

2 Outline Background ETS and lung cancer Tobacco industry response ETS and Cardiovascular disease ETS effects in infants/children

3 Outline Impact of smoking bans Health Business Third Hand Smoke passive vaping

4 Environmental Tobacco Smoke Background 1964 U.S. Surgeon General Report Smoking and Health 1986 U.S. Surgeon General Report The Health Consequences of Involuntary Smoking 1993 U.S. EPA Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders OSHA began rule making process which was blocked by the tobacco industry. There is no OSHA standard for secondhand smoke California EPA Health Effects of Exposure to Environmental Tobacco Smoke 2006 U.S. Surgeon General Carmona- The debate is over. Secondhand smoke causes disease and kills people.

5 Group A Carcinogens Arsenic Asbestos Benzene Environmental tobacco smoke Radon Vinyl chloride

6 Tobacco Smoke Constituents Arsenic Benzene Benzo[a]pyrene Cadmium Chromium VI Cresol Formaldehyde Lead Nitrosamines Phenol Polonium 210 Polycyclic aromatic hydrocarbons Vinyl chloride

7 Which emits more particulate matter into the air in 30 minutes, a 2L diesel engine or 3 smoldering cigarettes? CP

8 Particulate Matter From Cigarettes vs. Diesel Car Exhaust x mean particulate matter (PM) cigarettes vs. diesel exhaust Invernizzi G. Tob Control 13:219, 2004 CP

9 Lung Cancer Mortality and Smoking Standardized mortality rate for lung cancer/100, Non-smoker wives of non-smoker husbands Non-smoker wives of husbands with smoking habits Women with smoking habits 8.70 Non-smoker Familial passive smoking (-) Non-smoker Familial passive smoking (+) Cigarette smokers 21,895 69,645 17,366 Total 108,906 Population at enrollment Hirayama T. BMJ 282:183, 1981 CP

10 Secondhand Smoke Inhalation Study in Rats 21 day exposure to mainstream or sidestream smoke Rats resisted daily loading into exposure tubes Sidestream smoke exposure more toxic More rats in sidestream died spontaneously Squamous cell metaplasia in ciliated epithelia Wolf Reininghaus PM

11 1992 U.S. EPA Report ETS 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 ETS exposure

12 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.

13

14 Mortality in Non-Smoking Chinese Women Secondhand 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 ) 1.37 CVD mortality (CI ) Smoking at work: 1.79 lung cancer mortality (CI ) Wen W, BMJ 333:376, 2006

15 California EPA Report on ETS 2006 Excess Morbidity and Mortality in USA Pregnancy Low birth weight infants Pre Term Delivery Children 24,500 71,900 Asthma Episodes 202,300 Lower Respiratory Illness 150, ,000 Otitis Media Office Visits 790,000 SIDS 430 Adults Cardiac Deaths 46,000 (22,700-69,600) Lung Cancer Deaths 3,400

16 ETS 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 ETS exposure, mother or other persons, mother and other persons acute asthma exacerbations with exposure (RR 1.8 parent report & 1.7 by cotinine) FEV 1 with exposure Chilmonczyk BA. NEJM 328:1665, 1993

17 ETS Exposure and Urine Cotinine 1000 Cotinine (ng/ml) No exposure Mother or others smoke Mother and others smoke Chilmonczyk BA. NEJM 328:1665, 1993 CP

18 NNAL in Infants Exposed to Tobacco Smoke 47% of 144 infants had detectable urine NNAL and 98% had detectable urine cotinine 82% of the mothers were daily smokers and 72% lived in household that included other smokers Mean cigarettes smoked/week was significantly higher in infants where NNAL was detectable First study to show carcinogen (NNK) uptake by infants exposed to tobacco smoke Hecht SS, et al. Cancer Epid Biomarkers Prev; 15:988-92, 2006

19 Secondhand Smoke & Behavioral Problems In Children Prospective birth cohort study - 2 Germany cities 5,991 children born between 1995 and 1998 Behavioral problems 10 years after birth Emotional symptoms Conduct problems Hyperactivity/inattention Peer relationship problems Compared with children not exposed to tobacco smoke, children exposed both pre- and postnatally to tobacco smoke had twice the estimated risk [95% confidence interval (CI), ] of being classified as abnormal Ruckinger et al. Environmental Health Perspectives. Online 12/1/09.

20 ETS and Casino Patrons 18 nonsmokers with no ETS exposure for several days prior to 4 hour casino visit Spot urine before visit and 24 hour urine after visit NNAL metabolite of tobacco specificcarcinogen NNK urine cotinine (p<0.0001) and total NNAL (p=0.0004) from baseline Anderson KE, et al. Cancer Epidemiol Biomarkers Prev, 12:1544, 2003

21 Secondhand Smoke and Alveoli Damage on MRI 58 Adults 13 current or former smokers, 22 nonsmokers with heavy SHS exposure, 23 nonsmokers with less SHS exposure Heavy SHS exposure = living with a smoker 10 years Helium diffusion MRI detects microscopic alveoli rupture Alveoli rupture detectable in 57% of smokers and 33% of nonsmokers with heavy SHS exposure but 4% of nonsmokers with less SHS exposure Wang, C. Rad. Soc. N.A. Nov 2007

22 Smoking and Multiple Sclerosis Smokers have 40-80% risk of MS than nonsmokers Nurses Health Study: RR 1.6 (95% CI ) in current smokers vs nonsmokers Norwegian Study: RR 1.81 (95% CI ) in current and past smokers vs nonsmokers risk of MS before age 16 in children exposed to parental smoking. RR 2.12 (95% CI ) Mikaeloff, Y. Brain. 2007;130:2589.

23 Passive Smoking 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 Passive smoke 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

24 ETS and Coronary Circulation Acute 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 ETS exposure in hospital smoking room Abrupt reduction in coronary flow velocity reserve in nonsmokers Otsuka, R. JAMA 286: , 2001

25

26 ETS and Coronary Heart Disease 4729 men age followed for 20 years Baseline tobacco use status and serum cotinine Nonsmokers classified as light ETS exposure ( 0.7 ng/ml) or heavy ETS exposure ( ng/ml) hazard ratios for heavy ETS exposure especially in first (3.73; CI ) and second (1.95; CI ) 5 year follow-up Risk of CHD among heavy ETS exposure similar to light smokers (1-9 cpd) Whincup PH, et al. BMJ, doi: /bmj (published 30 June 2004)

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

28 ETS Exposure and Flight Attendants Mailed survey of flight attendants 2053 (14%) completed Excluded: Respondents with a personal history of smoking (n = 748) Non smokers with a history of respiratory tract diseases before the age of 18 years (n = 298) The remaining 1007 respondents form the study sample. Ebbert et al. Environ Health Sep 26;6:28.

29

30 ETS Exposure and Flight Attendants 2 Age-adjusted OR * * * 0 * p 0.05 Sinusitis Pneumonia Middle Ear Infection Hay Fever COPD Bronchitis Asthma Allergies Ebbert et al. Environ Health Sep 26;6:28.

31 ETS and Cats Risk of Lymphoma Feline malignant lymphoma similar to human non-hodgkin s lymphoma Case control study of 80 cats with feline lymphoma vs 114 controls with renal disease Owners surveyed for household ETS exposure for the 2 years preceding diagnosis Bertone ER. Am J Epidemiol 156: , 2002

32 ETS and Cats Risk of Lymphoma (cont.) RR for feline lymphoma 2.4 (95% CI ) with any ETS exposure to 3.2 (95% CI ) with 5 years ETS exposure Linear trend (i.e. dose response) p=0.003 Bertone ER. Am J Epidemiol 156: , 2002

33 Effect of Smoke-Free Workplaces Systematic review of 23 studies Prevalence of smoking by 3.8% smoking in continuing smokers by 3.1 CPD If all workplaces were smoke-free, per capita consumption of cigarettes would by 4.5% in USA and 7.6% in UK $1.7 billion and 310 million loss to tobacco industry Fichtenberg CM & Glantz SA. BMJ 325:188, 2002

34 Smoke-Free New York City 2004 Employment in NYC bars and restaurants highest in over a decade Business tax receipts in bars and restaurants by 8.7% Bar licenses by 234 Bar restaurant air quality significantly improved ( air cotinine by 85%) 97% compliance smoking prevalence 21.6% in 2002 to 19.3% in 2003

35 Lexington, Kentucky July 1, 2003 Urban County Council by vote 11-3 made most public places (bars, restaurants, bowling alleys, and pool halls) smoke-free as of Sept In that single instance, the Council may have improved the health of Lexington more than any action the Board of Health could have done. Health Commissioner, John Poundstone, M.D. Smoking prevalence in Fayette County- 27.6% in % in 2005

36 Minnesota ETS policy results Prevalence of smoking decreased 27.1% from 22.1% in 1999 to 16.1% in 2010 USA nationwide smoking rate declined only 15% (CDC)

37 Smoke-Free Ordinances and Heart Attacks Helena, MT: Monthly admissions for AMI (CI to -0.3) Sargent, RP. BMJ 328:977, Pueblo & El Paso, CO: Admissions for AMI in Pueblo 257/100,000 person years 187 vs. El Paso (Post to Pre RR 0.73 vs. 0.97) Bartecchi, C. Circulation 114:1490, Piedmont Region, Italy: Admissions for AMI 11% (sex, age-adjusted rate ratio 0.89, CI ) Barone-Adesi, F. Eur Heart J 27:2468, Bowling Green & Kent, OH: 47% Admissions for CHD 3 years after ordinance. Khuder,SA. Prev Med 45:3,2007.

38 Airport smoking areas affect nearby sites Air monitors in smoking and adjacent nonsmoking areas at airports in Denver, Atlanta, Las Vegas, Salt Lake City and Washington measured particulate pollution for 2 weeks. Average level in micgms/cubic meter in smoking areas; 43.7 in adjacent areas vs. 8.0 in smoke free airports ref: MMWR Nov. 20,2012

39 SHS exposure in open settings When smokers were present, SHS levels were increased in outdoor areas and adjacent smoke-free indoor areas Ref: Sureda X et al; Environ health Perspect. 2013, May 7

40 The Debate is Over The Health Consequences of Involuntary Exposure to Tobacco Smoke Surgeon General Richard H. Carmona June 27, 2006

41 U.S. Surgeon General Report 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

42 U.S. Surgeon General Report 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.

43 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.

44 Third-hand smoke (THS) THS is the residual tobacco smoke that remains after a cigarette is extinguished. It can react with indoor nitrous acid to produce a carcinogen. It may collect on clothing, furniture or rugs. Need for more scientific understanding of the potential dangers of THS

45 Residential THS exposure --THS accumulate in smoker s homes and persists when smokers move out even after homes remain vacant for 2 months are cleaned and prepared for new residents. --Non smokers living in former smoker homes are exposed to THS in dust and on surfaces. Ref. (Matt Ge et al; Tob Control, 2011 Jan;20(1)

46 Passive Vaping E-cigarette use is booming Is there danger from passive vaping? Unsure No --McAuley et al (Inhal Toxicol, 2012 Oct:24(12):850-7 Maybe-- Schripp et al (Indoor Air, 2013 Feb;23(1); 25-31)