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Secondhand-smoke and CVD A Global Epidemic Richard D. Hurt, M.D. Professor of Medicine Director, Nicotine Dependence Center

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Presentation on theme: "Secondhand-smoke and CVD A Global Epidemic Richard D. Hurt, M.D. Professor of Medicine Director, Nicotine Dependence Center"— Presentation transcript:

1 Secondhand-smoke and CVD A Global Epidemic Richard D. Hurt, M.D. Professor of Medicine Director, Nicotine Dependence Center

2 Richard D Hurt MD Financial Disclosure 9/13 Current Industry Grants : 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 industrys 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 Lung Cancer Mortality and Smoking CP Standardized mortality rate for lung cancer/100,000 Hirayama T. BMJ 282:183, 1981 Population at enrollment Non-smoker wives of non-smoker husbands Non-smoker wives of husbands with smoking habits Women with smoking habits Cigarette smokers Non-smoker Familial passive smoking (+) Non-smoker Familial passive smoking (-) Total 108,906

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7 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.

8 Dr. Takeshi Hirayama The grandfather of epidemiology in Asia- Judith Mackay

9 Mortality in Non-Smoking Chinese Women Secondhand 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 ) 1.37 CVD mortality (CI ) Smoking at work: 1.79 lung cancer mortality (CI ) Wen W, BMJ 333:376, 2006

10 California EPA Report on SHS – 2006 Excess Morbidity and Mortality in USA Pregnancy Low birth weight infants Pre Term Delivery 24,50071,900 Children Asthma Episodes 202,300 Lower Respiratory Illness 150, ,000 Otitis Media Office Visits 790,000 SIDS430 Adults Cardiac Deaths 46,000 (22,700-69,600) Lung Cancer Deaths 3,400

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

12 SHS and Exacerbations of Asthma in Children 199 children with asthma 199 children with asthma Parental report of ETS exposure 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 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) acute asthma exacerbations with exposure (RR 1.8 parent report & 1.7 by cotinine) FEV 1 with exposure FEV 1 with exposure Chilmonczyk BA. NEJM 328:1665, 1993

13 SHS Exposure and Urine Cotinine

14 SOURCE: Pechacek & Babb, British Medical Journal, Pechacek TF & Babb S. BMJ 328:980-3, PubMed Central PMCID: PMC Tobacco Smoke & Cardiovascular Risk Tobacco Smoke & Cardiovascular Risk Non-linear Dose Response

15 Brief SHS Exposure and Aortic Function 16 male nonsmokers and 32 smokers (active or sham smoking) undergoing cardiac catheterization for chest pain 16 male nonsmokers and 32 smokers (active or sham smoking) undergoing cardiac catheterization for chest pain Aortic catheter to measure pressure and diameter Aortic catheter to measure pressure and diameter SHS exposure x 5 minutes vs. 1 cigarette vs. sham smoking SHS exposure x 5 minutes vs. 1 cigarette vs. sham smoking aortic distensibility of 21%, 27% and 0% aortic distensibility of 21%, 27% and 0% Stefanadis C. Ann Intern Med 128:426, 1998

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

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

19 SHS and Coronary Circulation Acute Effects Healthy smokers (n=15) and nonsmokers (n=15) Healthy smokers (n=15) and nonsmokers (n=15) Coronary flow velocity reserve measures by transthoracic doppler echocardiography Coronary flow velocity reserve measures by transthoracic doppler echocardiography Baseline and hyperemic (IV adenosine triphosphatae) phases Baseline and hyperemic (IV adenosine triphosphatae) phases 30 minute SHS exposure in hospital smoking room 30 minute SHS exposure in hospital smoking room Abrupt reduction in coronary flow velocity reserve in nonsmokers Abrupt reduction in coronary flow velocity reserve in nonsmokers Otsuka, R. JAMA 286: , 2001

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21 SHS and Coronary Heart Disease 4729 men age followed for 20 years 4729 men age followed for 20 years Baseline tobacco use status and serum cotinine Baseline tobacco use status and serum cotinine Nonsmokers classified as light SHS exposure ( 0.7 ng/ml) or heavy SHS exposure ( ng/ml) Nonsmokers classified as light SHS exposure ( 0.7 ng/ml) or heavy SHS exposure ( ng/ml) hazard ratios for heavy SHS exposure especially in first (3.73; CI ) and second (1.95; CI ) 5 year follow-up hazard ratios for heavy SHS exposure especially in first (3.73; CI ) and second (1.95; CI ) 5 year follow-up Risk of CHD among heavy SHS exposure similar to light smokers (1-9 cpd) Risk of CHD among heavy SHS exposure similar to light smokers (1-9 cpd) Whincup PH, et al. BMJ, doi: /bmj (published 30 June 2004)

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23 META-ANALYSIS of CHD RISK DUE to CHRONIC SHS among NEVER-SMOKERS Overall RR = 1.78 for active smokers Overall RR = 1.31 for passive smoking Most of the SHS exposures were spousal 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 Relative risk N = 29 studies

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

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

26 1992 U.S. EPA Report SHS is a Group A carcinogen (arsenic, asbestos, benzene, radon, vinyl chloride) SHS is a Group A carcinogen (arsenic, asbestos, benzene, radon, vinyl chloride) 3,000 lung cancer deaths/year in nonsmokers 3,000 lung cancer deaths/year in nonsmokers 8,000 to 26,000 new asthma cases in children 8,000 to 26,000 new asthma cases in children 150,000 to 300,000 cases of bronchitis and pneumonia in toddlers 150,000 to 300,000 cases of bronchitis and pneumonia in toddlers Smoke-free work place reduces SHS exposure Smoke-free work place reduces SHS exposure

27 Group A Carcinogens Arsenic Arsenic Asbestos Asbestos Benzene Benzene Secondhand smoke Secondhand smoke Radon Radon Vinyl chloride Vinyl chloride

28 …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.

29 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.

30 Howard H. Baker, Jr. Senator from Tennessee Chief of Staff in the Reagan White House Former Chair of the Board of Trustees, Mayo Foundation. Ambassador to Japan Baker, Donelson et al received $2.6M from cigarette companies in 1998 alone.

31 Senator Helms further complained about Secretary Sullivans statements… This position was further strengthened by a Howard Baker to Sununu call indicating that Sununu was understanding of our situation.

32 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. 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.

33 B. A High Level Advocate: Senator Bakers 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 Senators activities on our behalf. D. A Goodwill Ambassador: …the coming months will provide countless opportunities to maximize the Senators activities on our behalf.

34 Science for Hire Smoke-free indoor air policies cigarette consumption Smoke-free indoor air policies cigarette consumption Global ETS consultant program intended to influence public opinion on secondhand smoke 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. 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 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: , 2003

35 ETS Consultants Program 1987U.S. 1988Europe – France, Germany, Italy, Norway, Spain, Sweden, UK 1989Asia/Pacific – Australia, Hong Kong, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, Thailand 1991Latin America – Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, Venezuela Muggli ME, et al. Nicotine Tob Res 5: , 2003

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37 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.

38 Effect of Smoke-Free Restaurants on Teen Smoking Longitudinal 4-year, 3-wave study in Massachusetts youth from 301 communities Massachusetts youth age 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 ) Impeded transition from experimentation to established smoking Siegel, M et. al. Arch Pediatr Adolesc Med 162:477, 2008

39 Smoke-Free Ordinances and Heart Attacks Helena, MT: Monthly admissions for AMI (CI to -0.3) Helena, MT: Monthly admissions for AMI (CI to -0.3) Sargent, RP. BMJ 328:977, Pueblo & El Paso, CO: Admissions for AMI in Pueblo 257/100,000 person years 187 vs. El Paso (Post to Pre RR 0.73 vs. 0.97) Pueblo & El Paso, CO: Admissions for AMI in Pueblo 257/100,000 person years 187 vs. El Paso (Post to Pre RR 0.73 vs. 0.97) Bartecchi, C. Circualtion. 114:1490, Scotland : 19% Admissions for troponin confirmed Acute Coronary Syndrome 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 Bowling Green & Kent, OH: 47% Admissions for CHD 3 years after ordinance Khuder,SA. Prev Med 45:3,2007 Khuder,SA. Prev Med 45:3,2007

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

41 Olmsted County, MN Smoke free ordinances implemented on 2 different dates –January 1, 2002: smoke-free restaurant law (Ordinance 1) –October 1, 2007: all workplaces became smoke-free (Ordinance 2)

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

43 Secular Trends and Incidence of MI and SCD in Olmsted Co MN

44 Prevalence of Self-Reported High Cholesterol, Diabetes, Hypertension and Obesity in Minnesota, from the Behavioral Risk Factors Surveillance System (BRFSS) Prevalence (%) High CholesterolHypertension Prevalence (%) Diabetes Obesity (BMI 30 kg/m 2 )

45 Prevalence of Self-Reported Current Smoking in Minnesota, from Behavioral Risk Factors Surveillance System (BRFSS) Year Prevalence (%) Current Smokers

46 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

47 Smoke-free Laws and Reduced AMI How Could This Be True ? Non-linear dose response to SHS Non-linear dose response to SHS People with pre-existing CAD People with pre-existing CAD SHS platelet adhesiveness SHS platelet adhesiveness SHS Endothelial dysfunction arterial dilatation SHS Endothelial dysfunction arterial dilatation SHS Coronary velocity reserve SHS Coronary velocity reserve Juster HR, et al, Am J Public Health 97:2035, 2007

48 Effect of Smoke-Free Workplaces on Smoking Rates Systematic review of 23 studies Systematic review of 23 studies Prevalence of smoking by 3.8% Prevalence of smoking by 3.8% smoking in continuing smokers by 3.1 CPD 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 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 $1.7 billion and £310 million loss to tobacco industry Fichtenberg CM & Glantz SA. BMJ 325:188, 2002

49 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 isnt surprising when you consider that our dire predictions in the past rarely came true.

50 The Debate is Over The Health Consequences of Involuntary Exposure to Tobacco Smoke Surgeon General Richard H. Carmona June 27, 2006

51 U.S. Surgeon General Report Key Findings Detectable cotinine concentrations in 88% of non-smokers (1988) 43% (2002) Detectable cotinine concentrations in 88% of non-smokers (1988) 43% (2002) Secondhand smoke causes disease and premature death in children and adults Secondhand smoke causes disease and premature death in children and adults risk of SIDS, acute respiratory infections, ear infections and more severe asthma in exposed children risk of SIDS, acute respiratory infections, ear infections and more severe asthma in exposed childrenwww.surgeongeneral.gov/library/secondhandsmoke

52 U.S. Surgeon General Report Key Findings (cont.) Immediate adverse effects on C.V. system in exposed adults and causes heart disease and lung cancer Immediate adverse effects on C.V. system in exposed adults and causes heart disease and lung cancer No risk-free level of exposure No risk-free level of exposure Eliminating smoking indoors protects non-smokers but ventilation and/or separation do not. Eliminating smoking indoors protects non-smokers but ventilation and/or separation do not.www.surgeongeneral.gov/library/secondhandsmoke

53 2006 U.S. Surgeon General Report Cigarette Company Response Philip Morris- We are studying the report. R.J. Reynolds- …..does not change our views about secondhand smoke. There are still legitimate scientific questions concerning the reported risks of secondhand smoke. There are still legitimate scientific questions concerning the reported risks of secondhand smoke. People who dont want to work around it dont have to work at that establishment People who dont want to work around it dont have to work at that establishment

54 Public Health Policies Cigarette Companies Hate the Most Increase in cigarette taxes Increase in cigarette taxes Smoke-free workplace laws Smoke-free workplace laws Why? Why? cigarette consumption in continuing smokers on average 5 cpd cigarette consumption in continuing smokers on average 5 cpd the chance of a smoker to stop the chance of a smoker to stop the chance of a young person starting to smoke the chance of a young person starting to smoke

55 Public promises were intended to deceive the American public into believing that there was no risk associated with passive smoking and that Defendants would fund objective research to find definitive answers. Instead, over the decades that followed, Defendants took steps to undermine independent research, to fund research designed and controlled to generate industry favorable results, and to suppress adverse research results United States et.al. v. Philip Morris et. al. (2006) United States et.al. v. Philip Morris et. al. (2006) Racketeers Honorable Gladys Kessler, United States District Court for the District of Columbia

56 No matter how innocent they appear, the tobacco industry CANNOT BE TRUSTED!


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