Department of Epidemiology
Secondhand Smoke (SHS):
The Facts
Jonathan M. Samet, MD, MS
Institute for Global Tobacco Control
December 15, 2004
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
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 multinational corporations
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 SHS—effects and
control? No, but maintained by the industry.
What is SHS?
The Manufactured Cigarette
Tipping
paper
Filter
Monogra
m
Cigarette paper
Ink
Ventilation
holes
Plugwra
p
Paper
Cigarette Paper
Adhesive
Tobacco and
additives
Tobacco Smoke Terminology
Source: JM Samet
• 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
SHS OR ETS?
Some Terminology
•Active smoking
•Passive smoking
•Involuntary smoking
SHS or ETS
•SHS preferred
•ETS originated
with industry
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
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
Where does exposure
to SHS take place?
How is it measured?
Basic Concepts
Source(s):
Cigarettes smoked
Concentration:
Level(s) of marker(s) in air
Exposure:
contact with second-hand
smoke, concentration by
time
amount of material (smoke
components) entering the
body
exposure depends on places
where time spent
Dose:
Microenvironmental
Model:
Personal Exposure to CO Across a Day
(Klepeis, 1999)
(Klepeis, 1999)
Assessing Exposure to
Second-hand Smoke
• Questionnaires
–
–
–
sources
source strength
perceived exposure
• Direct Measurement
–
Biomarkers
• Indirect Assessment
–
–
Concentration measurements
Microenvironmental models
Biomarkers
Compounds measured in biological
materials
For SHS, biomarkers include:
– Nicotine
– Cotinine
– Carboxyhemoglobin
– Thiocyanate
Change in median (50 percentile) level of
cotinine among nonsmokers in the U.S.
ages 3 and over
0.2
ng/mL
0.2
Relative decline - greater than 75%
0.15
0.1
0.05
0.05
0
1988-91
1999
Source: Health and Nutrition Examination Survey (NHANES III & IV)
SHS Exposure
(Klepeis, 1999)
SHS Exposure
(Klepeis, 1999)
Surveillance Of Secondhand
Tobacco Smoke In Latin America
Ana Navas Acien
Project Coordinator
Institute for Global Tobacco
Control (IGTC)
Johns Hopkins Bloomberg School of
PH Baltimore, MD
Director: Jonathan Samet
Tobacco Control Program
Pan American Health Organization
(PAHO/WHO)
Washington DC
Regional Advisor: Armando Peruga
Nicotine monitoring
• Passive sampling of vapor-phase
nicotine
~ 120 monitors per country, 7-14 days
Nicotine filter
• 10% duplicates, 10% blanks (QC)
• Airborne nicotine concentration (µg/m3)
measured by gas-chromatography
Gas-chromatograph
Hospitals – nicotine (µg/m3)
12
8
4
P75
P50
p25
0
N=
Peru
Chile
Argentina
20
25
24
Costa Rica
22
Uruguay
27
Restaurants
Area
N
p50
p75
p90
Smoking
49
1.58
2.55
3.98
1.89 (1.58)
Non-smoking
16
0.67
0.99
2.41
1.45 (3.20)
12
Non-smoking area
8
4
0
Peru
N=
15
Chile
13
Argentina
8
15
Costa Rica
14
Uruguay
mean (SD)
City Government Buildings
– nicotine (µg/m3)
12
8
4
0
N=
Peru
Chile
Argentina
19
20
16
Costa Rica
18
Uruguay
21
P75
P50
p25
What are the health
effects of SHS
exposure?
Hirayama’s Pioneering 1981 Paper:
SHS and Lung Cancer in Japanese Women
BMJ 1981 Jan
17;282(6259):183-5
Lung Cancer Mortality in Women According to the
Presence or Absence of Direct and Familial
Indirect Smoking
Source: Hirayama 1981
1986 Surgeon General’s Report
C. Everett Koop, M.D.
Former U.S. Surgeon General
SHS and Lung Cancer:
Meta-analysis of Female Data
RR (95% CI) in lifelong nonsmokers – smoking vs nonsmoking spouse
Relative risk
10
1
0.1
Source:Hackshaw et al. BMJ 315:980-88; 1997.
1986: Three Key Reports
1992 EPA Risk Assessment
• Based on metaanalysis of 31 studies
• Extensively criticized
by the tobacco
industry
• Federal court decision
•
around methods
• Policy implications key
IARC 2002
•Involuntary
smoking (exposure
to secondhand or
'environmental'
tobacco smoke) is
carcinogenic to
humans (Group 1).
Adverse Effects of Exposure
to Secondhand Tobacco Smoke
Children
Adults
Can Exposures to SHS
be Reduced?
Reducing Exposure to SHS
Control source
- Reduce smoking
Change the source
Separate smokers and nonsmokers
Increase ventilation
Use air cleaning
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
What works?
 Elimination
of the source
What does not work?
• Separation of smokers and non-smokers in
the same space
• Ventilation
• Air cleaning
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.”
Alternative Products
FOR IMMEDIATE RELEASE
JT to Accelerate Expansion of
“Reduced Odor Cigarette Segment"
Tokyo, October 6, 2003 --- Japan Tobacco Inc. (JT) (TSE:2914)
announced today an initiative aimed at the "reduced odor cigarette
segment" through the launch of "Mild Seven Prime Super Lights
Box" (Mild Seven Prime / JPY 300 per pack) and a sales area
expansion of "Lucia Citrus Fresh Menthol" (Lucia / JPY 300 per
pack), starting November 4, 2003.
In its latest medium-term management plan, JT PLAN-V, JT stated
that the company is creating a new category of cigarettes with
reduced tobacco odors. The creation of this new segment is part of
JT's commitment to allow smokers and non-smokers to more easily
coexist.
Lucia is the first product in this category, launched in the Tokyo
metropolitan area, in February of this year. Following its successful
market entry in Tokyo, the brand's sales area was expanded into the
neighboring four prefectures in August. Since its launch, Lucia has
maintained market share at levels almost twice as large as other
newly marketed brands, and from November 4 onwards it will be
available nationwide.
Establishing Smokefree Places
• Hospitals
• Public Places
• Workplaces
• Transportation
• Restaurants
• Bars
Benefits of Smokefree Workplaces
Benefits for Employees
 Creates safe and
Benefits for Employer

Increased worker
productivity

carefully implemented
effort can reduce
smoking among
employees
Reduces health care
costs

Reduces maintenance
costs
 Clearly defined policy

Risk of fires reduced
healthy workplace
 Well planned and
leads to compliance
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 employer’s
potential legal liability
• Nonsmoking employees have received
settlements in cases based on their exposure to
SHS (Sweda 1997).
Change in worker protection
from SHS
Percent
70
68.6
63.0
60
Relative increase + 49.8%
50
45.8
40
30
20
10
3.0
0
1986
1992-93
1995-96
1998-99
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
Change in smoke-free workplace policy coverage among
indoor American workers by type of worker
Self-respondents ages 15 years and older
Percent
76
80
60
1992-93
71.3
1995-96
56.8
53.7
51.4
50.4
44.8
34.8
40
27.4
20
0
White collar
1998-99
Blue collar
Service
Smokers’ Beliefs About
Where Smoking Should Never Be Allowed
90
US minus CA
80
CA
78.7
% Smokers
70
60
58.1
58.3
57.7
54.8
50
47.4
42.0
40
37.4
30
31.9
20
16.7
10
10.5
6.2
0
Restaurants
Hospitals
Source: CPS 1995-96, 1998-99
Work Areas
Bars
Sports
Arenas
Numbers in red are 1995-96 levels
Malls
SHS and Controversy?
Maintained Controversy
about SHS Control
• Health effects
• Extent of exposure
• Control strategies
• Costs of control measures
History of effort to protect
nonsmokers in U.S. from SHS
5
Thousands
Congress imposes temporary
ban on smoking aboard flights
of less than 2 hrs duration
1988
CAB requires smoking
CalEPA report links
and nonsmoking
SHS to CHD & SIDS
seating
deaths in 1997
on airlines. July 1973
3
1st epidemiological
SG Jesse Steinfeld
studies published
calls for
linking ETS with
nonsmokers bill of
lung cancer Jan
NAS (Nov 1986) and
2
rights Jan. 1971
1981
Surgeon General (Dec.
EPA issues major
1986) release major
ICC restricts
report on SHS in
reviews on health
smoking to rear
adults and children
1
effects of ETS
20% of interstate
Jan 1993
buses.
Congress eliminates smoking aboard
virtually all commercial airlines
0
Feb 1991
1970
1975
1980
1985
1990
1995
2000
4
1st report to review
ETS effects Jan. 1972
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
Philip Morris Document (1998): Impact of smokefree 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
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
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 projectsApplied Studies –are also funded if
approved by the Board; such projects
are not normally reviewed or
recommended by the SAB.
Source: Bates No. 2021528170
“The massive effort
launched across the
tobacco industry
against one scientific
study is
remarkable.”
(The Lancet 2000;355(9211):1253)
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)
Philip Morris on Secondhand Smoke
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
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
What is the FCTC?
• First time WHO Member States have
harnessed the organization’s 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
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
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.
For More Information
• http://www.jhsph.edu/IGTC/index.ht
ml
• http://www.who.int/tobacco/en/
• http://www.cdc.gov/tobacco/sgr/sgr
_2004/chapters.htm