Secondhand Smoke:
An Evolution of Understanding
Sean Sharma, MD
About the Speaker
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Seeger High School
Wabash College
Indiana University School of
Medicine
Duke University Internal
Medicine & Pediatrics
Residency
St. Vincent Williamsport
Hospital
Topics of Discussion
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Historical Context
Mechanism of Secondhand Smoke (SHS)
Damage
Proven Outcomes of SHS Exposure
Reaching a Solution
Local Findings
Statewide Efforts
Secondhand Smoke History - 1972
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First Addressed in 1972 U.S. Surgeon
General’s Report
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“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
History - 1975
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Surgeon General’s Report 1975
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Smoking is “annoying” to nonsmokers
Elevated nicotine levels in the blood of nonsmokers may possibly cause atherosclerotic
disease
History – 1979 & 1982
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Surgeon General’s Report – 1979
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There is limited knowledge with regard to SHS, further studies
recommended
Surgeon General’s Report – 1982
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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”
History - 1984
Surgeon General Report on COPD
(Chronic Obstructive Pulmonary Disease)
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Increased awareness of damage caused by
parental smoking
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Respiratory disease
Short Term – Bronchitis and Pneumonia
– Long Term – Decreased Pulmonary Function
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Eye irritation in children
Lung damage recognized in nonsmoking adults
History - 1986
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Surgeon General’s Report – 1986
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Entire report, 359 pages, dedicated to The Health
Consequences of Involuntary Smoking
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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
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
History - 1986
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International Agency for Research on Cancer
– World Health Organization
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Passive smoking gives rise to some risk of cancer
National Research Council
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Estimated increased risk of lung cancer in a
nonsmoker married to a smoker – 25%
History – 1992
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EPA – SHS is a known human carcinogen
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>3,000 lung cancer deaths per year in
nonsmokers attributed to SHS - 1992
History - 2005
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EPA Revised Estimates in 2005
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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
History - 2006
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Entire report of the Surgeon General
dedicated to SHS – The Health
Consequences of Involuntary Exposure to
Secondhand Smoke – 727 pages
History – 2006: Major Findings
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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
Present - 2011
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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!
Nearly a Half Century of Reports
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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.
Mechanism
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How does Smoke or Secondhand Smoke
cause damage?
How Tobacco Smoke Causes Disease: The Biology &
Behavioral Basis for Smoking-Attributable Disease
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Office of the Surgeon General 2010
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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
Mechanism: How A Heart Attack Happens
Mechanism of Injury
R
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Exposure
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Increased Stickiness of Platelets
Damage Lining of Blood Vessels
Decreased Coronary Flow Velocity
Increase Levels of LDL “Bad Cholesterol”
Dose-Response is nonlinear –
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Rapid increased risk with short term exposure
Slower further increase with longer exposure
PROVEN OUTCOMES
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Limiting Smoke Exposure Saves Lives
Pueblo Heart Study Phase I & II
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Impact of Smoke-Free Ordinance in Pueblo, CO July
2003
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Extended Analysis after Three Years
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Rate of heart attack admissions decreased 27% in 18 months
Experimental Controls: Suburban Pueblo and Colorado Springs,
CO
Impact not only sustained, but increased:
41% decrease in heart attack admissions
Nine other studies have come to similar conclusions
Pueblo Heart Studies I & II
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Smoke-Free laws likely reduce heart attack
hospitalizations both by reducing SHS exposure,
and by reducing smoking at work and at home.
Initial response
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Decreased SHS
Subsequent response
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Decreased smokers
Smoke-Free home rules
Amazing Factoids
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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
Leading Causes of Preventable Death
1)
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Tobacco Abuse
– Half of all long-term smokers will eventually
die from their use of tobacco.
Obesity
Second Hand Smoke
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 . . .”
Thirdhand Smoke
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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
Reaching A Solution
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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
Helping Smokers Quit
1-800-QUIT NOW
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National Cancer Institute
National Institute of Health
United States Department of Health and
Human Services
1-800-QUIT NOW
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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.
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Why is Quitting Difficult?
Why do I need the Quitline?
Weight Gain Concerns?
Afraid of Failure?
1-800-QUIT NOW
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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
http://www.becomeanex.org/
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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.
Where Are We, Statewide?
ITPC (Indiana Tobacco Prevention & Cessation)
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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
ITPC Survey of Rural Indiana
ITPC Survey Results from Four Rural Counties:
•Clay, Lawrence, Montgomery, & Warren
ITPC Accomplishments: 10 Years
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High School Smoking Rates Down 42%
Historically Low Adult Smoking Rate 23%
30+ Smoke Free Communities
70 % of Schools Have Smoke Free Campus
ITPC: Still More to be Done
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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
Local Successes
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Warren County Indiana
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Largest Employers Going Smoke Free
Tobacco Free County Fair
Influencing Neighboring Counties
No Town Ordinances . . . Yet
Secondhand Smoke
1972  2011
References
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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.