Secondhand smoke, lung disease, & public health

Transcription

1 Overview Secondhand smoke, lung disease, & public health Mark D. Eisner, MD, MPH University of California, San Francisco Secondhand smoke (SHS) exposure scope of the problem How much asthma / COPD is attributable to SHS? Can SHS exacerbate asthma / COPD? SHS exposure, lung function, and cardiovascular mortality The workplace a nidus for change Coda: time to clear the air Mainstream Generation of SHS Sidestream SHS contains >4, chemical constituents 4/6 U.S. EPA criteria air pollutants emitted in SHS - PM, NO, SO, CO Tobacco smoke exposure what s s in a name? Chapman S, Tobacco Control Passive smoke / smoking First term for other people s s smoke Disliked by Helmut Wakeham at PM Environmental tobacco smoke Coined by Ragnar Rylander,, tobacco industry consultant More precise definition than passive smoking First use: proceedings of an industry sponsored meeting in 974 Secondhand smoke Neutral Most commonly used term in the media Now considered the preferred term SHS exposure Scope of the problem (Eisner MD. Environmental Health Persp ) How much OLD is due to SHS? Prevalence of detectable serum cotinine among U.S. adults (NHANES III). Adults with asthma Adults without asthma SHS has potent respiratory irritants - acrolein, formaldehyde Irritant and / or sensitizing mechanism Detectable cotinine (%) 86% (8 to 9%) 8% (8 to 86%) P =.8 for comparison

2 SHS is a cause of childhood asthma Lifetime SHS exposure and incident asthma Jaakkola,, AJPH OEHHA meta-analysis 85 studies 46, children 9 countries Pooled OR. (.4-4)* *in 9 studies that controlled for childhood atopy and smoking Odds Ratio* SHS exposure None to 49 5 to 99 to Cohort studies Case-control studies OEHHA. Cal EPA, 5 Strachan and Cook, Thorax 998 Workplace Home Combined *controlling for age, sex, parental atopy/asthma, education, pets, mold, occupational exposures Recent SHS exposure and chronic bronchitis (SAPALDIA Study) Longitudinal impact of SHS on CB SAPALDIA cohort study (4 never smokers) Javet et, al. Scand J Work Environ Health 5 4,97 never smoking adults (8-6 yrs) Any self-reported SHS exposure during the past months vs. none Cross-sectional sectional analysis Chronic bronchitis OR.65 (.6-.4).4) Dyspnea on exertion OR.4 (.8-.74).74) Odds ratio Developing CB Remission of CB None Any SHS Work SHS Other location *controlling for educational level Leuenberger et al, AJRCCM 994 Baseline SHS exposure (interview) Daily symptom diaries for years (6 x 4 week periods) Analysis controlled for age, sex, parental asthma / allergies, education, citizenship, BMI, occupational exposures to irritants Odds ratio Lifetime SHS and chronic bronchitis Robbins et al (Int( J Epidemiol 99) Risk of chronic bronchitis None Childhood only Adulthood only Both Controls for age, sex, education, past smoking (years), ambient air pollution * Lifetime SHS exposure and the risk of COPD Eisner et al. Environmental Research 5 Population-based sample of, adults aged years residing in contiguous 48 U.S. states Structured telephone interviews Cumulative lifetime home and work exposure ascertained COPD = self-reported physician diagnosis of chronic bronchitis, emphysema, or COPD

3 SHS and COPD - analysis Lifetime SHS exposure and the risk of COPD Eisner et al. Environmental Research 5 Prenatal SHS exposure Cumulative lifetime home SHS exposure Cumulative lifetime work SHS exposure Risk of COPD Potential confounders - age, sex, race, smoking, education, marital status, workplace VGDF Odds ratio Q Q Q Q4 Q Q Q4 Q Prenatal Home Work Controlling for age, sex, race, smoking, education, marital status, & workplace VGDF How much OLD is attributable to SHS exposure? ADULT ASTHMA Total SHS exposure / cases Can SHS exposure exacerbate asthma? Eisner et al, Environ Health Persp,, n=5 adults with asthma Eye or nose irritation COPD Home SHS exposure / cases Workplace SHS exposure /5 cases Personal Badge Monitor Nicotine Level Cough, wheeze, or chest tightness CHILDHOOD ASTHMA / cases (>, children -7 yrs in USA) Extra bronchodilator use 7 day monitoring period Telephone survey P for trend OR SHS Exposure and Asthma Exacerbation Sensory Respiratory Bronchodilator irritation symptoms use (extra) symptoms Badge Nicotine Level None Lower Higher SHS exposure and longitudinal health outcomes Eisner MD, et al. Thorax 49 adults with asthma - 8 month follow-up SHS exposure measurement ED Visits (OR, 95% CI) Hospitalization (OR, 95% CI) Baseline, past 7 d None.. Any.8 (. to 6.4) 6.6 (. to ) Baseline, past 7 d None.. Lower (- hr/wk).5 (.9 to 6.6) 4.6 (.7 to 4) Higher (+ hr/wk).4 (. to.). (.5 to ) *controlling for age, gender, education, income

4 SHS exposure and risk of hospitalization for asthma Eisner et al, Thorax 5 Cohort of 8 adults hospitalized for asthma age 65+ yrs. Exposure = hair nicotine, past month SHS exposure and re-hospitalization asthma () Proportion free of re-hospitalization Time until re-hospitalization (days) HR.5.5 * * Hair nicotine, past month Tertile Tertile Tertile Cox proportional hazards analysis controlling for age, sex, race, educational attainment, martial status, and previous smoking history SHS exposure and pulmonary function in female NHANES III participants Eisner MD. Environ Health Persp FEV (ml/sec) Asthma * * General population, no asthma SHS exposure and exacerbation of pre-existing existing adult asthma Ostro et al, AJRCCM 994 Prospective cohort of 64 adult non-smokers with asthma Age 8-7 yrs (mean 45 yrs) Daily diary - SHS at home and work, respiratory symptoms month period Analysis using -day lagged exposure SHS exposure and adult asthma status SHS and asthma exacerbation.5 OR.5 No ETS ETS.5 Cough Dyspnea Noc. Sx Rest. Activity

5 SHS exposure is common in COPD Eisner et al, BMC Pulmonary Medicine % Survey Badge nicotine Urine cotinine Survey assessed SHS during the past 7 days in 6 microenvironments: home, another person's home, traveling in a car or vehicle, workplace, bars and nightclubs, and other locations Can SHS exposure exacerbate COPD? (Eisner et al, BMC Pulmonary Medicine 6) 77 adults with COPD; current non-smokers; direct SHS monitoring Longitudinal analysis of SHS exposure status at year follow-up Controlling for age, sex, race, education, past smoking history COPD severity Physical Diseasespecific health status (SF-) HRQL Dyspnea (MRC) Urine cotinine tertile tertile tertile SHS exposure, pulmonary function, and cardiovascular mortality (Eisner et al, Annals of Epidemiology, in press) Longitudinal impact of SHS exposure on FEV Mean mls per yrs of SHS exposure FEV (age,sex,ht,race) FEV (+ed,inc,marital) 57 never smoking adults aged 5-97 yrs Home - total Spouse/SO Work P<.5 in all cases SHS exposure and CV mortality The workplace nidus for change Intersection of science & public policy SHS exposure Health effects Public policy Worker protection

6 Workplace SHS exposure how common is it? Determinants of workplace exposure Time: relative person-minutes of SHS exposure in different environments (California Time-Activity Survey 99) Time Occupation Workplace SHS Exposure Work Home Outdoor Other indoor Workplace smoking policy Adult Male Nonsmokers Adult Female Nonsmokers Occupation and workplace SHS exposure Occupation and Smoke-free Workplaces (U.S. Current Population Survey, 99-9) 9) Time Workplace SHS Exposure Workplace smoking policy Occupation Proportion smoke-free Health-diagnosing Teachers Personal services Motor vehicle operators Machine Operators Food service Occupation and nicotine concentration (8-hr average, ug/m ) 6-cities study, Jenkins et al, 999 Occupation Nicotine (median) Nicotine (95 th %tile) RSP (median) Managerial Professional Clerical.. 5 Services Servers Bartenders Home only Workplace smoking policy and SHS exposure Time Workplace SHS Exposure Workplace smoking policy Occupation

7 Workplace smoking policies in the U.S. (U.S. Current Population Survey, 99-9) 9) Workplace Smoking Restrictions by Degree of Strength proportion Smoke-free Smoking allowed Restricted All White Collar Blue Collar Service Median nicotine concentration (ug/m ) Workplace smoking policy and nicotine concentration WellWorks project, Hammond et al, JAMA 995 Office Nonoffice Allowed Restricted Banned Workplace smoking ban and respiratory health (Eisner, JAMA 998) Does SHS exposure cause respiratory symptoms and lung function impairment? Bartenders exposed to high SHS levels: x other workplaces CA Assembly Bill amended Labor Code no smoking in bars and taverns //98 Effect of reduced SHS exposure on respiratory symptoms and lung function Study Framework Sampling Strategy BASELINE (/-//97) Respiratory Sx Sensory Irritation Sx Pulmonary Function BARS SMOKE-FREE Decreased SHS Exposure FOLLOW-UP (/-/8/98) Respiratory Sx Sensory Irritation Sx Pulmonary Function Random sample of SF bars and taverns 5 of 8 bars participated (%) Interview and spirometry 54 of 67 bartenders who work > daytime shift per week completed baseline (8%) 5 of 54 subjects completed follow-up (98%)

8 Change in: Study Outcome Variables Respiratory symptoms - cough, wheeze, SOB Sensory irritation symptoms - eye, nose, throat Pulmonary function - FEV, FVC, FEF 5-75 Baseline bartender characteristics (n=5) Age (mean, sd) 4.5 (4) Gender (% F) 8% Educ (some college) 76% Current Bar Employment. (.5-8.) (median years, IQR) Ever Smoked 76% Current Smoking 45% Respiratory and sensory irritation symptoms Pulmonary Function Improvement 4.% Sx (Any) Baseline Follow-up Resolution Respiratory 9 (74%) 7 (%) 59% Sensory 4 (77%) (9%) 77% p<. ml/sec % FEV FVC National smoking ban in Scotland: impact on respiratory health of bartenders Menzies et al, JAMA 6 Scottish smoking ban respiratory health of bartenders improves N=77 bartenders

9 Decline in respiratory symptoms in hospitality workers after Norway smoking ban Eagan et al, Eur Resp J 5 Impact of Irish smoking ban on particulate pollution in 4 Dublin pubs (McCaffrey et al, Eur Resp J 5) % Morning cough * * * Daytime cough May-4 Phlegm cough Oct-4 Dyspnea Wheezing * p<.5 Micrograms /m 5 4 Average PM.5 Levels Pre Ban Post Ban Time of Sampling Popn based sample of 55 hospitality workers before and 5 mos after workplace smoking ban Irish smoking ban and bartender lung function year later Agnew et al, Eur Resp J 6 Work shift changes in lung function among 6 bartenders in British Columbia Dimich-Ward et al, 998 Change in mean percent predicted value (%) FVC PEF ml/sec FEV FEF5%-75% Smoke-free workplace ordinance and incidence of acute MI -Helena, MT - hospital in km -D/C dx of AMI Sargent, BMJ 4 Workplace SHS policy aspects CA statewide smoking legislation California Smoke-Free Workplace Law AB Jan, 995 prohibits smoking in most workplaces Jan,998 included bars and taverns Cosponsored by California Restaurant Association, AFL-CIO, CA medical association Threat of workers compensation and Americans with Disabilities Act claims Intersection of epidemiology and policy Pre-emption emption of local regulation e.g,, AB excludes businesses that are solely owner operated, hotel rooms / lobbies, hotel banquet rooms, employee break rooms (direct ventilation), etc. Smoke-free ordinance

10 %* 5 4 Compliance with CA smoke-free workplace law (Weber,( Weber, Tob Tob Cont ) *proportion with no smoking patrons observed Free-standing bars Bar/restuarants Tough Sexy Rebellious Independent Socially acceptable Smoking in film Hollywood back to the past Glantz, AJPH 4 Tobacco use in films and adolescent smoking Sargent, BMJ, Smoking incidents per hour Cross-sectional Random sample of 499 schoolchildren 9-5 yrs 95 Tobacco use in films and adolescent smoking Sargent, BMJ Movie smoking and adolescent smoking initiation Dalton, Lancet Tried smoking Median occurrences of Tobacco use 9 (49-5) Relative Risk* adolescents aged -4 Never smokers at baseline Surveyed -6 mos later % initiated smoking Q (-5) Q (5-96) Q (96-664) Q4 (665-58).5 Quartiles of tobacco use *controlling for grade, sex, school, friend smoking, sibling smoking, parent smoking, receptivity to tobacco ads, school performance, sensation seeking propensity, rebelliousness, self-esteem, parent education, authoritative parenting, parental smoking disapproval

11 SHS - conclusions SHS exposure is common (still) SHS may cause new cases of asthma, COPD, and impaired lung function SHS exacerbates obstructive lung disease Worker health has been powerful force for policies prohibiting public smoking Film / media a powerful contrary force Intersection of science & policy epidemiologic evidence on health effects = basis for law Coda: time to clear the air Eisner, JAMA 6 Surgeon general 6: SHS causes lung cancer, heart disease, and shortened life span Workplace smoking bans rapidly improve health Bans are effective, popular, and revenue friendly And people quit smoking at higher rates