Secondhand Smoke (SHS):The Facts

Jonathan M. Samet, MD, MS

Institute for Global Tobacco Control

December 15, 2004

Department of Epidemiology

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 multi-

national 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

Tobacco and additives

Tipping

paper

Cigarette Paper Adhesive

Plugwrap

Paper

FilterMonogram

Ink

Cigarette paper

Ventilation holes

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

Sou

rce:

JM

Sam

et

Some Terminology•Active smoking•Passive smoking•Involuntary smoking

SHS or ETS•SHS preferred•ETS originated with industry

SHS OR ETS?

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?

Source(s): Cigarettes smoked

Concentration: Level(s) of marker(s) in air

Exposure: contact with second-hand smoke, concentration by time

Dose: amount of material (smoke components) entering the body

Microenvironmental Model:

exposure depends on places where time spent

Basic Concepts

(Klepeis, 1999)

Personal Exposure to CO Across a Day

(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

0.05

0

0.05

0.1

0.15

0.2ng/mL

1988-91 1999

Relative decline - greater than 75%

Source: Health and Nutrition Examination Survey (NHANES III & IV)

(Klepeis, 1999)

SHS Exposure

(Klepeis, 1999)

SHS Exposure

Surveillance Of Secondhand Tobacco Smoke In Latin America

Ana Navas AcienProject Coordinator

Institute for Global Tobacco Control (IGTC)

Johns Hopkins Bloomberg School of PH Baltimore, MD

Tobacco Control Program

Pan American Health Organization (PAHO/WHO)

Washington DC

Director: Jonathan Samet

Regional Advisor: Armando Peruga

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 Gas-chromatograph

Nicotine filter

P75P50p250

4

8

12

Peru Chile Argentina Costa Rica Uruguay

N = 20 25 24 22 27

Hospitals – nicotine (µg/m3)

Restaurants

0

4

8

12

Peru Chile Argentina Costa Rica Uruguay

N = 15 13 8 15 14

Non-smoking area

AreaN p50 p75 p90 mean (SD)

49 1.58 2.55 3.98 1.89 (1.58)Smoking

Non-smoking 16 0.67 0.99 2.41 1.45 (3.20)

P75P50p25

4

8

12

Peru Chile Argentina Costa Rica Uruguay

N = 19 20 16 18 21

0

City Government Buildings – nicotine (µg/m3)

What are the health effects of SHS

exposure?

BMJ 1981 Jan 17;282(6259):183-5

Hirayama’s Pioneering 1981 Paper: SHS and Lung Cancer in Japanese Women

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

0.1

1

10

SHS and Lung Cancer:Meta-analysis of Female Data

RR (95% CI) in lifelong nonsmokers – smoking vs nonsmoking spouse

Source:Hackshaw et al. BMJ 315:980-88; 1997.

Rel

ativ

e ri

sk

1986: Three Key Reports

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

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

IARC 2002

Adverse Effects of Exposure to Secondhand Tobacco Smoke

Children

Adults

Can Exposures to SHS be Reduced?

Control source- Reduce smoking

Change the source

Separate smokers and nonsmokers

Increase ventilation

Use air cleaning

Reducing Exposure to SHS

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.”

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.

Alternative Products

Establishing Smokefree Places

• Hospitals

• Public Places

• Workplaces

• Transportation

• Restaurants

• Bars

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

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

1986 1992-93 1995-96 1998-990

10

20

30

40

50

60

70

Percent

All estimates based on 1998-99 CPS data should be considered preliminary1986 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

3.0

45.8

63.068.6

Relative increase + 49.8%

Change in smoke-free workplace policy coverage among indoor American workers by type of worker

Self-respondents ages 15 years and older

53.7

27.4

34.8

71.3

44.8

50.4

76

51.4

56.8

White collar Blue collar Service 0

20

40

60

80

Percent

1992-93 1995-96 1998-99

0

10

20

30

40

50

60

70

80

90

Restaurants Hospitals Work Areas Bars SportsArenas

Malls

% S

mo

ke

rs

US minus CA

CA

16.7

42.0

58.3

78.7

31.9

54.8

6.2

10.5

47.4

58.1

37.4

57.7

Smokers’ Beliefs AboutWhere Smoking Should Never Be Allowed

Source: CPS 1995-96, 1998-99 Numbers in red are 1995-96 levels

SHS and Controversy?

Maintained Controversy about SHS Control

• Health effects• Extent of exposure• Control strategies• Costs of control measures

History of effort to protect History of effort to protect nonsmokers in U.S. from SHSnonsmokers in U.S. from SHS

1970 1975 1980 1985 1990 1995 2000

0

1

2

3

4

5Thousands

SG Jesse Steinfeld calls for nonsmokers bill of rights Jan. 1971

ICC restricts smoking to rear 20% of interstate buses.

1st report to review ETS effects

Jan. 1972

MN passes 1st lawrequiring employers to

protect nonsmokers June 1975

1st epidemiological studies published linking ETS with lung cancer Jan 1981

NAS (Nov 1986) and Surgeon General (Dec. 1986) release major reviews on health effects of ETS

Congress imposes temporary ban on smoking aboard flights of less than 2 hrs duration 1988

NCI publishes airline study demonstrates nonsmokers seated

in nonsmoking section significantly exposed to ETS Feb.

1989

Congress eliminates smoking aboard virtually all commercial airlinesFeb 1991

EPA issues major report on SHS in adults and children Jan 1993

CalEPA report links SHS to CHD & SIDS deaths in 1997

CAB requires smokingand nonsmoking seating on airlines. July 1973

Philip Morris Document (1998): Impact of smoke-free workplace policies on Cessation

Smokers facing workplace restrictions have a 84% higher quit rate than average

Anticipate a 74% increase in quitting rate if smoking was banned in all workplaces

10% industry decline 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 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

“The massive effort launched across the tobacco industry against one scientific study is remarkable.”

(The Lancet 2000;355(9211):1253)

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)

BMJ VOLUME 326 17

MAY 2003

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.html• http://www.who.int/tobacco/en/• http://www.cdc.gov/tobacco/sgr/sgr_2

004/chapters.htm