Secondhand Smoke: An Evolution of Understanding

1. Secondhand Smoke: An Evolution of Understanding Sean Sharma, MD

2. About the Speaker • Seeger High School • Wabash College • Indiana University School of Medicine • Duke University Internal Medicine & Pediatrics Residency • St. Vincent Williamsport Hospital

3. Topics of Discussion • Historical Context • Mechanism of Secondhand Smoke (SHS) Damage • Proven Outcomes of SHS Exposure • Reaching a Solution • Local Findings • Statewide Efforts

4. Secondhand Smoke History - 1972 • First Addressed in 1972 U.S. Surgeon General’s Report • “An atmosphere contaminated with tobacco smoke can contribute to the discomfort of many individuals” • Mention of possible harm to individuals who already have chronic heart or lung disease

5. History - 1975 • Surgeon General’s Report 1975 • Smoking is “annoying” to nonsmokers • Elevated nicotine levels in the blood of non-smokers may possibly cause atherosclerotic disease

6. History – 1979 & 1982 • Surgeon General’s Report – 1979 • There is limited knowledge with regard to SHS, further studies recommended • Surgeon General’s Report – 1982 • Three studies completed, concern raised of link with lung cancer in nonsmokers • “Although the currently available evidence is not sufficient to conclude that passive or involuntary smoking causes lung cancer in nonsmokers, the evidence does raise concern about a possible serious public health problem”

7. History - 1984 • Surgeon General Report on COPD (Chronic Obstructive Pulmonary Disease) • Increased awareness of damage caused by parental smoking • Respiratory disease • Short Term – Bronchitis and Pneumonia • Long Term – Decreased Pulmonary Function • Eye irritation in children • Lung damage recognized in nonsmoking adults

8. History - 1986 • Surgeon General’s Report – 1986 • Entire report, 359 pages, dedicated to The Health Consequences of Involuntary Smoking • Conclusive evidence: Second Hand Smoke causes Lung Cancer in nonsmokers • Simply separating smokers and nonsmokers within the same airspace does not eliminate SHS • SHS exposure to children may lead to COPD in adulthood

9. History - 1986 “The right of smokers to smoke ends where their behavior affects the health and well-being of others; furthermore, it is the smokers’ responsibility to ensure that they do not expose nonsmokers to their potential [sic] harmful effects of tobacco smoke” - Dr. C. Everett Koop, Surgeon General

10. History - 1986 • International Agency for Research on Cancer – World Health Organization • Passive smoking gives rise to some risk of cancer • National Research Council • Estimated increased risk of lung cancer in a nonsmoker married to a smoker – 25%

11. History – 1992 • EPA – SHS is a known human carcinogen • >3,000 lung cancer deaths per year in nonsmokers attributed to SHS - 1992

12. History - 2005 • EPA Revised Estimates in 2005 • Up to 9,000 excess lung cancer deaths/year • Up to 70,000 excess heart disease deaths/year • Up to 500 SIDS deaths/year • Up to 72,000 Premature/LBW Infants per year • 200,000 episodes of childhood asthma • 300,000 cases of lower respiratory child illnesses • Nearly 1,000,000 cases of middle ear infections

13. History - 2006 • Entire report of the Surgeon General dedicated to SHS – The Health Consequences of Involuntary Exposure to Secondhand Smoke – 727 pages

14. History – 2006: Major Findings • Causes premature death in nonsmoking children & adults • Children exposed to SHS are at increased risk for SIDS, acute respiratory infections, ear problems, & severe asthma • Children of smokers have slowed lung growth • Exposure of adults to SHS has immediate adverse effects on cardiac health, causing CAD & lung cancer • Separating smokers and nonsmokers is not effective, only complete elimination of smoking from indoor spaces fully protects nonsmokers • There is NO RISK-FREE LEVEL OF EXPOSURE

15. Present - 2011 • All data relates solely to nonsmokers, and the effect of involuntary smoke exposure • Remember what we know and when we figured it out. • It is time for strong action!

16. Nearly a Half Century of Reports • In 1964, the Surgeon General released a landmark report that characterized the dangers of smoking as they were then understood (U.S. Department of Health, Education, and Welfare 1964). • During the intervening 45 years, 29 SGR’s have documented the overwhelming & conclusive biologic, epidemiologic, behavioral, & pharmacologic evidence that tobacco use in any form is harmful & can be deadly. The past 29 reports have established a long list of health consequences & diseases caused by tobacco use & exposure to tobacco smoke.

17. Mechanism • How does Smoke or Secondhand Smoke cause damage?

18. How Tobacco Smoke Causes Disease: The Biology & Behavioral Basis for Smoking-Attributable DiseaseU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Surgeon General 2010 • DNA Adduct Formation – A piece of DNA that is bonded covalently to a cancer causing chemical. Genetic and epigenetic changes lead to cancer through alteration of critical cellular pathways that foster uncontrolled cell growth and defeat of normal mechanisms to restrain their growth and spread. • Endothelial Injury - Damage to the lining of coronary and peripheral arteries through an oxidative process. • Platelet Activation - Increased risk of thrombosis or clot formation blocking blood flow. • Protease/Antiprotease Imbalance - Increase destructive enzyme activity that reduces the lung’s elasticity by damaging its structure and causing emphysema. • Atherogenic Lipid Profile – Abnormal cholesterol metabolism causing an increase in triglycerides and a decrease in high-density lipoprotein cholesterol • Germ Cell Damage – Sperm and possibly eggs are damaged in smokers effecting fertility, pregnancy viability, and anomalies in offspring

19. Mechanism: How A Heart Attack Happens

20. RISK Mechanism of Injury • Increased Stickiness of Platelets • Damage Lining of Blood Vessels • Decreased Coronary Flow Velocity • Increase Levels of LDL “Bad Cholesterol” • Dose-Response is nonlinear – • Rapid increased risk with short term exposure • Slower further increase with longer exposure Exposure

21. PROVEN OUTCOMES • Limiting Smoke Exposure Saves Lives

22. Pueblo Heart Study Phase I & II • Impact of Smoke-Free Ordinance in Pueblo, CO July 2003 • Rate of heart attack admissions decreased 27% in 18 months • Experimental Controls: Suburban Pueblo and Colorado Springs, CO • Extended Analysis after Three Years • Impact not only sustained, but increased: • 41% decrease in heart attack admissions • Nine other studies have come to similar conclusions

23. Pueblo Heart Studies I & II • Smoke-Free laws likely reduce heart attack hospitalizations both by reducing SHS exposure, and by reducing smoking at work and at home. • Initial response • Decreased SHS • Subsequent response • Decreased smokers • Smoke-Free home rules

24. Amazing Factoids • More deaths are caused each year by tobacco use than by all deaths from (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined (Source: CDC) TOBACCO USE DEATHS > Combined Deaths from HIV , Drug Use, Alcohol Use, Car Accidents, Suicides, & Murders

25. Leading Causes of Preventable Death • Tobacco Abuse • Half of all long-term smokers will eventually die from their use of tobacco. • Obesity • Second Hand Smoke

26. Thirdhand Smoke “. . . An invisible yet toxic brew of gases . . . clinging to smokers’ hair and clothing, not to mention cushions and carpeting, that lingers long after secondhand smoke has cleared from a room. The residue includes heavy metals, carcinogens, and even radioactive materials . . .”

27. Thirdhand Smoke • Contains at least 11 highly carcinogenic compounds • Simply closing the door, opening the window, going outside or whatever other justification that is used, is not enough

28. Reaching A Solution • Workplace smoking restrictions are effective • Workplace restrictions lead to less smoking • Smoke-free workplaces is the only effective way • A majority of U.S. workers are now protected • Smoke-free policies do not have any proven adverse economic impact on industry • Exposure of nonsmokers cannot be controlled by air cleaning or mechanical air exchange • Total bans on indoor smoking substantially reduce SHS exposure even with incomplete compliance – and with full compliance risk is eliminated

29. Helping Smokers Quit

30. 1-800-QUIT NOW • National Cancer Institute • National Institute of Health • United States Department of Health and Human Services

31. 1-800-QUIT NOW • When you call, a trained quit coach in your state will work with you to help you quit and avoid the things that tempt you back into the habit. • Why is Quitting Difficult? • Why do I need the Quitline? • Weight Gain Concerns? • Afraid of Failure?

32. 1-800-QUIT NOW • Reminders are Helpful – Not Nagging • It Needs to Be the Smoker’s Choice • Making a Plan Increases Success • Support Before, During, and After is Crucial • Even a Failed Attempt is Success

33. http://www.becomeanex.org/

34. The way to quit is to re-learn everything you thought you knew about addiction and your smoking habit. And that involves taking a long, hard look at all the ways smoking has become a part of your life. You’ll pick your habit apart into little pieces you can tackle one by one. Once you begin, you’ll start to look at quitting not as one huge war, but as a series of small battles you can actually see yourself winning. • Re-learn all those things in your life that are tied to smoking.

35. Where Are We, Statewide?ITPC (Indiana Tobacco Prevention & Cessation) • Change the cultural perception and social acceptability of tobacco use in Indiana • Prevent initiation of tobacco use by Indiana youth • Assist tobacco users in cessation • Assist in reduction and protection from secondhand smoke • Support the enforcement of tobacco laws concerning the sale of tobacco to youth and use of tobacco by youth • Eliminate minority health disparities

36. ITPC Survey Results from Four Rural Counties: • Clay, Lawrence, Montgomery, & Warren ITPC Survey of Rural Indiana

37. ITPC Accomplishments: 10 Years • High School Smoking Rates Down 42% • Historically Low Adult Smoking Rate 23% • 30+ Smoke Free Communities • 70 % of Schools Have Smoke Free Campus

38. ITPC: Still More to be Done • 10,000 Deaths Per Year From Tobacco (State) • Nearly 8 Billion Dollars in Costs Yearly (State) • Costs of Program Covered by Master Settlement Agreement not Taxes

39. Local Successes • Warren County Indiana • Largest Employers Going Smoke Free • Tobacco Free County Fair • Influencing Neighboring Counties • No Town Ordinances . . . Yet

40. Secondhand Smoke 1972  2011

41. References • U.S. Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. • U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010. • http://www.cdc.gov/tobacco/secondhand_smoke/ • Rabin, Roni. A New Cigarette Hazard: ‘Third-Hand Smoke’, The New York Times, Jan. 3, 2009.