Secondhand Smoke SHS: The Facts

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Secondhand Smoke (SHS)The Facts
Department of Epidemiology

• Jonathan M. Samet, MD, MS
• Institute for Global Tobacco Control
• December 15, 2004

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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

3
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

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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 SHSeffects and
  control? No, but maintained by the industry.

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• What is SHS?

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The Manufactured Cigarette
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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

Source JM Samet
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SHS OR ETS?

• Some Terminology
• Active smoking
• Passive smoking
• Involuntary smoking

• SHS or ETS
• SHS preferred
• ETS originated
• with industry

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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

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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

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• Where does exposure to SHS take place?
• How is it measured?

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Basic Concepts
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Personal Exposure to CO Across a Day
(Klepeis, 1999)
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(Klepeis, 1999)
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Assessing Exposure to Second-hand Smoke

• Questionnaires
• sources
• source strength
• perceived exposure
• Direct Measurement
• Biomarkers
• Indirect Assessment
• Concentration measurements
• Microenvironmental models

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Biomarkers

• Compounds measured in biological materials
• For SHS, biomarkers include
• Nicotine
• Cotinine
• Carboxyhemoglobin
• Thiocyanate

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Change in median (50 percentile) level of
cotinine among nonsmokers in the U.S. ages 3 and
over
Relative decline - greater than 75
1988-91 1999
Source Health and Nutrition Examination Survey
(NHANES III IV)
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SHS Exposure
(Klepeis, 1999)
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SHS Exposure
(Klepeis, 1999)
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Surveillance Of Secondhand Tobacco Smoke In
Latin America
Ana Navas Acien Project Coordinator
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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

Nicotine filter
Gas-chromatograph
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Hospitals nicotine (µg/m3)
12
8
4
P75 P50 p25
0
Peru
Chile
Argentina
Costa Rica
Uruguay
N
20
25
24
22
27
24
Restaurants
Non-smoking area
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City Government Buildings nicotine (µg/m3)
12
8
4
0
Peru
Chile
Argentina
Costa Rica
Uruguay
N
19
20
16
18
21
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• What are the health effects of SHS exposure?

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Hirayamas Pioneering 1981 Paper SHS and Lung
Cancer in Japanese Women
BMJ 1981 Jan 17282(6259)183-5
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Lung Cancer Mortality in Women According to the
Presence or Absence of Direct and Familial
Indirect Smoking
Source Hirayama 1981
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1986 Surgeon Generals Report
C. Everett Koop, M.D.Former U.S. Surgeon General
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SHS and Lung CancerMeta-analysis of Female Data
RR (95 CI) in lifelong nonsmokers smoking vs
nonsmoking spouse
Relative risk
SourceHackshaw et al. BMJ 315980-88 1997.
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1986 Three Key Reports
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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

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IARC 2002

• Involuntary smoking (exposure to secondhand or
  'environmental' tobacco smoke) is carcinogenic to
  humans (Group 1).

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Adverse Effects of Exposure to Secondhand
Tobacco Smoke
Children
Adults
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• Can Exposures to SHS be Reduced?

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Reducing Exposure to SHS

• Control source
• Reduce smoking
• Change the source
• Separate smokers and nonsmokers
• Increase ventilation
• Use air cleaning

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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

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What works?

• Elimination of the source
• What does not work?
• Separation of smokers and non-smokers in the same
  space
• Ventilation
• Air cleaning

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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.
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Alternative Products
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Establishing Smokefree Places

• Hospitals
• Public Places
• Workplaces
• Transportation
• Restaurants
• Bars

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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

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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 employers
  potential legal liability
• Nonsmoking employees have received settlements in
  cases based on their exposure to SHS (Sweda
  1997).

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Change in worker protection from SHS
68.6
63.0
Relative increase 49.8
45.8
3.0
All estimates based on 1998-99 CPS data should be
considered preliminary 1986 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
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Change in smoke-free workplace policy coverage
among indoor American workers by type of worker
Self-respondents ages 15 years and older
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Smokers Beliefs About Where Smoking Should Never
Be Allowed
Numbers in red are 1995-96 levels
Source CPS 1995-96, 1998-99
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SHS and Controversy?

• Maintained Controversy about SHS Control
• Health effects
• Extent of exposure
• Control strategies
• Costs of control measures

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History of effort to protect nonsmokers in U.S.
from SHS
Congress imposes temporary ban on smoking aboard
flights of less than 2 hrs duration 1988
CalEPA report links SHS to CHD SIDS deaths in
1997
CAB requires smoking and nonsmoking seating on
airlines. July 1973
1st epidemiological studies published linking ETS
with lung cancer Jan 1981
SG Jesse Steinfeld calls for nonsmokers bill of
rights Jan. 1971 ICC restricts smoking to rear
20 of interstate buses.
NAS (Nov 1986) and Surgeon General (Dec. 1986)
release major reviews on health effects of ETS
EPA issues major report on SHS in adults and
children Jan 1993
Congress eliminates smoking aboard virtually all
commercial airlines Feb 1991
MN passes 1st law requiring employers to protect
nonsmokers June 1975
NCI publishes airline study demonstrates
nonsmokers seated in nonsmoking section
significantly exposed to ETS Feb. 1989
1st report to review ETS effects Jan. 1972
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Philip Morris Document (1998) Impact of
smoke-free workplace policies on Cessation
Smokers facing workplace restrictions have a 84
higher quit rate than average
10 industry decline if smoking was banned in all
workplaces
Anticipate a 74 increase in quitting rate if
smoking was banned in all workplaces
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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
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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
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The massive effort launched across the tobacco
industry against one scientific study is
remarkable.
(The Lancet 2000355(9211)1253)
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BMJ VOLUME 326 17 MAY 2003
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)
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Philip Morris on Secondhand Smoke
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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

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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

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What is the FCTC?

• First time WHO Member States have harnessed the
  organizations 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
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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

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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.

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For More Information

• http//www.jhsph.edu/IGTC/index.html
• http//www.who.int/tobacco/en/
• http//www.cdc.gov/tobacco/sgr/sgr_2004/chapters.h
  tm

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