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Secondhand-smoke and CVD A Global Epidemic

Secondhand-smoke and CVD A Global Epidemic. Richard D. Hurt, M.D. Professor of Medicine Director, Nicotine Dependence Center http:// ndc.mayo.edu. Richard D Hurt MD Financial Disclosure 9/13. Current Industry Grants 2010-13: Pfizer Medical Education Grant Consulting past 12 months: None

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Secondhand-smoke and CVD A Global Epidemic

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  1. Secondhand-smoke and CVD A Global Epidemic Richard D. Hurt, M.D. Professor of Medicine Director, Nicotine Dependence Center http://ndc.mayo.edu

  2. Richard D Hurt MDFinancial Disclosure 9/13 • Current Industry Grants 2010-13: Pfizer Medical Education Grant • Consulting past 12 months: None • HAVE NOT AND WILL NEVER ACCEPT ANY MONEY FROM THE TOBACCO INDUSTRY

  3. Objectives • Discuss the science behind secondhand smoke and its effect on the various organ systems and production of disease. • Demonstrate knowledge of the cigarette industry’s efforts to confuse and deceive the public over decades. • Demonstrate knowledge of the acute effects of secondhand smoke and its effect on the vasculature • Understand the positive effects of smoke-free workplace laws on the reduction of acute myocardial infarction.

  4. The increase in smoking has resulted in the progressive elimination of one non-smokers’ sanctuary after another – drawing-room, bedroom, work-room, place of entertainment, conveyance, and finally, of late years, hospital ward and sanatorium, even when and where patients seriously ill from respiratory diseases are under treatment.

  5. Non-smoker wives of non-smokerhusbands Non-smoker wives of husbandswith smoking habits Women with smoking habits Cigarettesmokers Standardized mortality ratefor lung cancer/100,000 Total108,906 Non-smoker Familial passivesmoking (+) Non-smoker Familial passivesmoking (-) Population at enrollment Hirayama T. BMJ 282:183, 1981 CP969217-4 Lung Cancer Mortality and Smoking

  6. 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. 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.

  7. Dr. Takeshi Hirayama 1923-1995 “The grandfather of epidemiology in Asia”- Judith Mackay

  8. 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

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

  10. DEATHS GLOBALLY from SECONDHAND SMOKE Secondhand Smoke is tobacco smoke that is exhaled by smokers orgiven off by burning tobacco • Second-hand smoke causes an estimated 603,000 premature deaths worldwide each year • 87% of adult SHS deaths are due to ischaemic heart disease , Oberg M, et al., Lancet. 2011.

  11. 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

  12. 55.8 Cotinine (ng/mL) 13.1 5.6 Noexposure Mother orothers smoke Mother andothers smoke Chilmonczyk BA. NEJM 328:1665, 1993 CP969217-3 SHS Exposure and Urine Cotinine

  13. Tobacco Smoke & Cardiovascular RiskNon-linear Dose Response Pechacek TF & Babb S. BMJ 328:980-3, 2004. PubMed Central PMCID: PMC404492 SOURCE: Pechacek & Babb, British Medical Journal, 2004.

  14. 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

  15. SHS and Aortic Function in 11y/o’s • Atherosclerosis prevention trial in 386 Finnish children • Serum cotinine concentrations to measure SHS exposure • Abdominal aorta ultrasound- stiffness index, elastic modulous, and distensibility • ↑ Aortic stiffness with higher cotinine Kallio K et al Pediatrics 123:e267, 2009

  16. Kallio, K. et al. Pediatrics 2009;123:e267-e273

  17. 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

  18. 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)

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

  20. META-ANALYSIS of CHD RISK DUE to CHRONIC SHS among NEVER-SMOKERS N = 29 studies • Overall RR = 1.78 for active smokers • Overall RR = 1.31 for passive smoking • Most of the SHS exposures were spousal Relative risk Barnoya & Glantz. (2005). Circulation 111:2684–2698. Long-term SHS exposure in the work or home is associated with a 30% increased risk for CHD in adult nonsmokers

  21. Secondhand Smoke and Peripheral Artery Disease (PAD) • 1209 Nonsmoking Chinese women randomly identified and screened for PAD • PAD defined by symptoms of intermittent claudication (IC) or ankle-brachial index (ABI) <0.090 • 39.5% reported SHS exposure at home or workplace • Risk of PAD (by IC) OR 1.87, CI 1.30-2.35, (by ABI) OR 1.47 CI 1.07-2.03 He Y, et al. Circulation,118:1535 , 2008

  22. Secondhand Smoke and COPD • Population-based sample 2113 adults age 55-75 • Random digit dial and telephone interview to ascertain lifetime SHS exposure • Self-reported physician diagnosis of chronic bronchitis, emphysema in COPD • Higher cumulative lifetime SHS exposure → greater risk of COPD (OR 1.55, CI 1.09-2.21) Eisner MD, et al. Environ Health. 4:7, 2005

  23. 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

  24. Group A Carcinogens • Arsenic • Asbestos • Benzene • Secondhand smoke • Radon • Vinyl chloride

  25. …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.

  26. 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.

  27. 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.

  28. 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.

  29. On July 23, 1989 Senator Baker completes his one year “cooling off” period during which he could not by law, lobby his former employer. Since he will now begin to play a more active role in our government affairs programs, I think it is timely to suggest ways he can most effectively complement our activities. The Senator is in a special position to accomplish four goals:… A. Unique Intelligence Source: …On broad policy matters such as taxation, regulation, personnel, and other Administration policies, he gives this Company the intelligence that few if any other consultants can duplicate.

  30. B. A High Level Advocate: Senator Baker’s attachment to this Company gives us an effective high level advocate of our policies. C. A Master Strategist: …he is particularly skilled in the art of tactics…especially with how this Company should position itself through a protracted policy debate. D. A Goodwill Ambassador: …the coming months will provide countless opportunities to maximize the Senator’s activities on our behalf.

  31. 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

  32. 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

  33. 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.

  34. Effect of Smoke-Free Restaurants on Teen Smoking • Longitudinal 4-year, 3-wave study in Massachusetts youth from 301 communities. • 3834 Massachusetts youth age 12-17 at baseline • Interviewed 3x over period of 4 years • Youth living in towns with strong smoke-free restaurant laws were less likely to progress to established smoking (OR 0.60, 95% CI 0.42-0.85) • Impeded transition from experimentation to established smoking Siegel, M et. al. Arch Pediatr Adolesc Med 162:477, 2008

  35. 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

  36. AMI Counts Per 100,000 Person Years Bartecchi, C. Circualtion. 114:1490, 2006.

  37. Olmsted County, MN • Smoke free ordinances implemented on2 different dates • January 1, 2002:smoke-free restaurant law (Ordinance 1) • October 1, 2007: all workplaces becamesmoke-free(Ordinance 2)

  38. Olmsted County AMI & SCD per 100,000 Population/Year Post-Ordinance Pre-Ordinance Hurt R.D. et al Arch TNT Med

  39. Secular Trends and Incidence of MI and SCD in Olmsted Co MN

  40. Prevalence of Self-Reported High Cholesterol, Diabetes, Hypertension and Obesity in Minnesota, 1999-2010 fromthe Behavioral Risk Factors Surveillance System (BRFSS) High Cholesterol Hypertension Prevalence (%) Prevalence (%) Diabetes Obesity (BMI 30 kg/m2) Prevalence (%) Prevalence (%)

  41. Prevalence of Self-Reported Current Smokingin Minnesota, 1999-2010 from BehavioralRisk Factors Surveillance System (BRFSS) Current Smokers Prevalence (%) Year

  42. 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

  43. 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

  44. Effect of Smoke-Free Workplaces on Smoking Rates • 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

  45. 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.

  46. “The Debate is Over”The Health Consequences of Involuntary Exposure to Tobacco Smoke Surgeon General Richard H. CarmonaJune 27, 2006

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