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Health Effects of Tobacco Use & Exposure to Second Hand Smoke Roberta Ferrence Ontario Tobacco Research Unit Dalla Lana School of Public Health September.

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Presentation on theme: "Health Effects of Tobacco Use & Exposure to Second Hand Smoke Roberta Ferrence Ontario Tobacco Research Unit Dalla Lana School of Public Health September."— Presentation transcript:

1 Health Effects of Tobacco Use & Exposure to Second Hand Smoke Roberta Ferrence Ontario Tobacco Research Unit Dalla Lana School of Public Health September 17, 2014

2 Ontario Tobacco Research Unit Tobacco as Medicine 16c Used to alleviate discomfort 16c Used to alleviate discomfort 17c Belief that smoking provided protection from the plague 17c Belief that smoking provided protection from the plague 1614 a Scottish doctor praised tobacco, which 1614 a Scottish doctor praised tobacco, which “prepareth the stomach for meat; it maketh a clear voice: it maketh a sweet breath… in a few words, it is the princess of physical plants” “prepareth the stomach for meat; it maketh a clear voice: it maketh a sweet breath… in a few words, it is the princess of physical plants”

3 Ontario Tobacco Research Unit However, others disagreed… "loathsome to the eye, hateful to the nose, harmful to the brain" and "dangerous to the lungs.” - King James I (1604): ‘A Counterblaste to Tobacco’

4 Ontario Tobacco Research Unit …and were amazingly accurate 19c Anti-tobacco crusade Dr. Joel Shew of England attributed delirium tremens, impotency, insanity and cancer to effects of smoking and chewing.

5 Ontario Tobacco Research Unit 20c Thinking on Tobacco Cigarettes = “Coffin nails” Cigarettes = “Coffin nails” Irritation model: Irritation model: Cigarettes thought safer since less irritating than other forms of tobacco Cigarettes thought safer since less irritating than other forms of tobacco Underlying health concern in ads: Underlying health concern in ads: 1936: “Ask your doctor about a light smoke” 1936: “Ask your doctor about a light smoke” 1946: “More doctors smoke Camels” 1946: “More doctors smoke Camels”

6 Ontario Tobacco Research Unit Landmarks in Early Scientific Knowledge on Smoking and Health 1939: Muller finds statistical link between smoking and cancer in small-scale study 1939: Muller finds statistical link between smoking and cancer in small-scale study 1950: 3 large-scale epidemiological studies linking smoking to lung cancer (Levin, Wynder & Graham, and Doll & Hill) 1950: 3 large-scale epidemiological studies linking smoking to lung cancer (Levin, Wynder & Graham, and Doll & Hill) 1952: Doll and Hill conclude "association between smoking and carcinoma of the lung is real" 1952: Doll and Hill conclude "association between smoking and carcinoma of the lung is real"

7 Ontario Tobacco Research Unit Two Firsts 1953: Wynder, Graham and Croninger show cigarette tar painted on mice causes tumours First lab evidence for carcinogenic effect of smoking First lab evidence for carcinogenic effect of smoking First evidence for carcinogens in “Thirdhand Smoke” First evidence for carcinogens in “Thirdhand Smoke”

8 Ontario Tobacco Research Unit More Early Epidemiology 1954: Doll and Hill publish first results of British Doctors Study: Smoking associated with increased lung cancer and contributes to heart disease 1954: Doll and Hill publish first results of British Doctors Study: Smoking associated with increased lung cancer and contributes to heart disease 1956: Auerbach: Dose Response 1956: Auerbach: Dose Response Smoking induces precancerous changes in lung that increase with amount smoked & decline after quitting. Smoking induces precancerous changes in lung that increase with amount smoked & decline after quitting. Doll and Hill: Mortality Doll and Hill: Mortality Lung cancer mortality in heavy smokers x 20 nonsmokers; Lung cancer mortality in heavy smokers x 20 nonsmokers; death rates decline in proportion to length of time since stopping. death rates decline in proportion to length of time since stopping.

9 Ontario Tobacco Research Unit Establishing a Causal Relationship 1957: The British MRC conclude "direct causal connection" between smoking and lung cancer 1957: The British MRC conclude "direct causal connection" between smoking and lung cancer 1958: Hammond and Horn report smoking causes lung cancer and coronary artery disease 1958: Hammond and Horn report smoking causes lung cancer and coronary artery disease 1962: Royal College of Physicians concludes smoking causes lung cancer, bronchitis; probably contributes to coronary heart disease and other diseases 1962: Royal College of Physicians concludes smoking causes lung cancer, bronchitis; probably contributes to coronary heart disease and other diseases

10 Ontario Tobacco Research Unit 1964 Surgeon General’s Report on Smoking and Health Based on 7000 articles relating to smoking and disease Concluded that cigarette smoking is a: Cause of Lung & Laryngeal Cancer in men Cause of Lung & Laryngeal Cancer in men Probable cause of Lung Cancer in women Probable cause of Lung Cancer in women Most important cause of Chronic Bronchitis in both sexes Most important cause of Chronic Bronchitis in both sexes

11 Ontario Tobacco Research Unit The Health Consequences of Smoking: Reports of the US Surgeon General Number of diseases and conditions associated with tobacco use skyrocket Number of diseases and conditions associated with tobacco use skyrocket (SGRs 1979, 1985, 1989, 2004, 2014) (SGRs 1979, 1985, 1989, 2004, 2014) Reports on specific groups (Youth 1994, 2012, Minorities 1998, Women 1980, 2001), Diseases (CVD 1983, Lung disease 1984) Cessation 1990, Secondhand Smoke 1984, 2006 and Addiction 1988 Reports on specific groups (Youth 1994, 2012, Minorities 1998, Women 1980, 2001), Diseases (CVD 1983, Lung disease 1984) Cessation 1990, Secondhand Smoke 1984, 2006 and Addiction 1988

12 Ontario Tobacco Research Unit Tobacco is Addictive: US 1988: The Health Consequences of Smoking: NICOTINE ADDICTION, A Report of the US Surgeon General concluded: Cigarettes and other forms of tobacco are addicting Cigarettes and other forms of tobacco are addicting Nicotine: drug in tobacco that causes addiction Nicotine: drug in tobacco that causes addiction Pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to heroin and cocaine Pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to heroin and cocaine

13 Ontario Tobacco Research Unit Tobacco is Addictive: Canada 1989: Royal Society of Canada, Tobacco, Nicotine and Addiction concluded: “Cigarette smoking can and frequently does meet all the criteria for addiction” “Cigarette smoking can and frequently does meet all the criteria for addiction” Nicotine is the addictive agent in tobacco Nicotine is the addictive agent in tobacco

14 Ontario Tobacco Research Unit Health Effects of Tobacco Use Current Evidence SGR 2010: How Tobacco Causes Disease SGR 2014: The Health Consequences of Smoking: 50 Years of Progress

15 Ontario Tobacco Research Unit Carbon Monoxide Decreases availability of oxygen in blood increasing risk of heart attack Decreases availability of oxygen in blood increasing risk of heart attack Slows oxidation processes Slows oxidation processes Direct effects on Direct effects on Cardiac function Cardiac function Heart structure Heart structure Blood vessels Blood vessels Raises cholesterol levels, white blood cells counts and other risk factors for heart disease Raises cholesterol levels, white blood cells counts and other risk factors for heart disease

16 Ontario Tobacco Research Unit “Tar” and Smoke Gases Gases Particulates: Heart and Respiratory effects Particulates: Heart and Respiratory effects Cell damage: Cancer Cell damage: Cancer Different effects at different stages of lifespan Different effects at different stages of lifespan

17 Ontario Tobacco Research Unit Nicotine Physiological effects Acetylcholine Acetylcholine Releases catecholamines (dopamine etc.) Releases catecholamines (dopamine etc.) Increases heart rate, respiration and BP Increases heart rate, respiration and BP Increases blood glucose levels Increases blood glucose levels Rate of absorption determines CV effects Fast “bolus” for smoking Fast “bolus” for smoking Slow release for patch, gum Slow release for patch, gum Environmental effects Combines with nitrous acid indoors and forms new tobacco-specific carcinogens Combines with nitrous acid indoors and forms new tobacco-specific carcinogens

18 Ontario Tobacco Research Unit More on Nicotine Acute toxicity Acute toxicity Activates many pathways to increase risk of disease Activates many pathways to increase risk of disease Prenatal exposure adversely affect brain development Prenatal exposure adversely affect brain development Contributes to preterm delivery and stillbirth Contributes to preterm delivery and stillbirth May affect adolescent brain development May affect adolescent brain development Increases vascularization, which may promote tumor growth, atherosclerosis or spread cancer Increases vascularization, which may promote tumor growth, atherosclerosis or spread cancer May predispose to obesity and diabetes May predispose to obesity and diabetes May prime brain for cocaine use May prime brain for cocaine use

19 Ontario Tobacco Research Unit Tobacco and Cardiovascular Disease Smoking causes: More deaths from CVD than Cancer Ischemic Heart Disease Ischemic Heart Disease Stroke Peripheral vascular disease Stroke Peripheral vascular disease Aortic Aneurysm Aortic Aneurysm Type II Diabetes (Dose Response) Type II Diabetes (Dose Response)

20 Ontario Tobacco Research Unit Not just Lung Cancer Lip, Oral cavity, Nasal, Paranasal sinus, Pharynx, Larynx and Esophagus Lip, Oral cavity, Nasal, Paranasal sinus, Pharynx, Larynx and Esophagus Urinary Bladder and Ureter Urinary Bladder and Ureter Kidney Kidney Liver Liver Colorectal Colorectal Pancreas Pancreas Uterine Cervix Uterine Cervix Stomach Stomach Bone marrow (myeloid leukemia) Bone marrow (myeloid leukemia) Suspected cause of breast cancer Suspected cause of breast cancer

21 Ontario Tobacco Research Unit Continued Smoking Affects Cancer Patients Increase in adverse health outcomes Increase in adverse health outcomes Quitting smoking improves outcomes Quitting smoking improves outcomes Increased risk of dying of any cause Increased risk of dying of any cause Increased risk of secondary cancers Increased risk of secondary cancers May raise risk of recurrence, poorer response to treatment, and increased toxicity from treatment May raise risk of recurrence, poorer response to treatment, and increased toxicity from treatment

22 Ontario Tobacco Research Unit Effects of Smoking on Prostate Cancer No evidence at this point for causal relationship No evidence at this point for causal relationship May have higher risk of death May have higher risk of death May have higher risk of advanced-stage disease and risk of progression May have higher risk of advanced-stage disease and risk of progression

23 Ontario Tobacco Research Unit Smoking Causes Respiratory Disease COLD or COPD COLD or COPD Pneumonia, Asthma, TB Pneumonia, Asthma, TB Children and Adolescents: Children and Adolescents: impaired lung growth, coughing, phlegm, wheezing, asthma symptoms impaired lung growth, coughing, phlegm, wheezing, asthma symptoms Adults: Adults: Decline in lung function Decline in lung function May cause Idiopathic pulmonary fibrosis May cause Idiopathic pulmonary fibrosis

24 Ontario Tobacco Research Unit Smoking Causes Reproductive Effects Fetal death and stillbirths Fetal death and stillbirths SIDS SIDS Ectopic pregnancy Ectopic pregnancy Reduced fertility in mother and offspring Reduced fertility in mother and offspring Low Birth Weight, shortened gestation and preterm delivery Low Birth Weight, shortened gestation and preterm delivery Orofacial clefts and other birth defects Orofacial clefts and other birth defects Other pregnancy complications Other pregnancy complications

25 Ontario Tobacco Research Unit Other Effects Immune disorders: Rheumatoid arthritis Immune disorders: Rheumatoid arthritis Cataracts, AMD, Cataracts, AMD, Respiratory and healing complications of surgery Respiratory and healing complications of surgery Low Bone Density Low Bone Density Hip Fractures Hip Fractures Peptic Ulcer Disease, if helicobacter pylori positive Peptic Ulcer Disease, if helicobacter pylori positive

26 Ontario Tobacco Research Unit Smoking Likely Causes Breast Cancer in all women Breast Cancer in all women Root surface Dental Caries Root surface Dental Caries Failure of dental implants Failure of dental implants Erectile Dysfunction (ED) Erectile Dysfunction (ED) Multiple Sclerosis Multiple Sclerosis Crohn’s Disease Crohn’s Disease

27 Ontario Tobacco Research Unit Smoking and Lung Cancer Most lung cancer related to smoking in West: Most lung cancer related to smoking in West:  75% of cases in women  84% of cases in men In Asia, 65%-95% occur in non-smokers In Asia, 65%-95% occur in non-smokers 1.2 M cases worldwide and increasing 1.2 M cases worldwide and increasing 5 yr. survival: 15% 5 yr. survival: 15% Duration of smoking & amount smoked Duration of smoking & amount smoked Interacts with radon, asbestos, high heat cooking Interacts with radon, asbestos, high heat cooking

28 Ontario Tobacco Research Unit Smoking & Breast Cancer New research shows increased risk New research shows increased risk among heavy and long term smokers Important interaction with Second Hand Smoke Important interaction with Second Hand Smoke Misclassification Misclassification Expert Panel on Tobacco Smoke and Breast Cancer (2009) Expert Panel on Tobacco Smoke and Breast Cancer (2009) “ The relationships between active smoking and both pre- and post-menopausal breast cancer are consistent with causality.”

29 Ontario Tobacco Research Unit Smokeless Tobacco (ST) Wet Snuff and chewing tobacco Wet Snuff and chewing tobacco Chewing tobacco and snuff contain 28 cancer- causing agents. Chewing tobacco and snuff contain 28 cancer- causing agents. Most harmful are tobacco-specific nitrosamines (TSNAs) Most harmful are tobacco-specific nitrosamines (TSNAs) Formed during growing, curing, fermenting, and aging of tobacco. Formed during growing, curing, fermenting, and aging of tobacco.

30 Ontario Tobacco Research Unit Smokeless Tobacco (ST) Many other carcinogens in ST Many other carcinogens in ST Oral cancer Oral cancer Nicotine in ST Nicotine in ST 3-4 times amount delivered by a cigarette 3-4 times amount delivered by a cigarette Absorbed more slowly than from cigarettes Absorbed more slowly than from cigarettes More nicotine per dose absorbed More nicotine per dose absorbed Stays in bloodstream longer Stays in bloodstream longer Cardiovascular effects and nicotine addiction Cardiovascular effects and nicotine addiction Relationship with CVD, diabetes and reproductive effects under study Relationship with CVD, diabetes and reproductive effects under study

31 Ontario Tobacco Research Unit Smokeless Tobacco (ST) Formation of additional carcinogens depends on processing and storage Formation of additional carcinogens depends on processing and storage Swedish ST (“snus”) may have fewer carcinogens than average North American ST Swedish ST (“snus”) may have fewer carcinogens than average North American ST New evidence for increased cancers (pancreatic) New evidence for increased cancers (pancreatic) Health risk may be as low as 10% of that for cigarettes; still a 2-fold risk. Health risk may be as low as 10% of that for cigarettes; still a 2-fold risk. Insufficient research at this point Insufficient research at this point

32 Ontario Tobacco Research Unit Quitting at any age provides major health benefits Quitting at any age provides major health benefits No elevated risk of lung cancer if quit < age 30 No elevated risk of lung cancer if quit < age 30 At age 50, risk of death is reduced by 50% compared to continuing smokers At age 50, risk of death is reduced by 50% compared to continuing smokers At age 40, 50% less risk than at age 50 At age 40, 50% less risk than at age 50 Even at advanced ages, immediate respiratory, cardiac and wound healing benefits, reduced CHD risk and some reduction in cancer risk Even at advanced ages, immediate respiratory, cardiac and wound healing benefits, reduced CHD risk and some reduction in cancer risk Reduction in Risk after Quitting

33 Health Effects of Second Hand Smoke

34 Ontario Tobacco Research Unit What is Second Hand Smoke? SHS formed from smoldering a cigarette or other tobacco product SHS formed from smoldering a cigarette or other tobacco product Smoke exhaled by smoker Smoke exhaled by smoker Fetal exposure comes from mother’s active smoking and other SHS in environment Fetal exposure comes from mother’s active smoking and other SHS in environment

35 Ontario Tobacco Research Unit History of Evidence on SHS 1979 SGR: several adverse respiratory outcomes + acute cardiovascular effects 1979 SGR: several adverse respiratory outcomes + acute cardiovascular effects 1982 SGR raised concern re lung cancer 1982 SGR raised concern re lung cancer 1992 EPA concluded SHS: 1992 EPA concluded SHS: Caused lung cancer and lower respiratory illnesses in children Caused lung cancer and lower respiratory illnesses in children Type A carcinogen Type A carcinogen 1997 Cal EPA, 1998 UK, 1999 WHO 1997 Cal EPA, 1998 UK, 1999 WHO

36 Ontario Tobacco Research Unit 2001: Second Hand Smoke causes:  In Adults: Heart disease, Lung cancer, Nasal sinus cancer  In Children: SIDS, Fetal Growth impairment, Low Birth Weight, Respiratory diseases, Asthma exacerbation, Middle ear disease

37 Ontario Tobacco Research Unit SHS May also Cause: In Adults: Stroke, Breast cancer, Cervical cancer, Miscarriages In Adults: Stroke, Breast cancer, Cervical cancer, Miscarriages In Children: Adverse impact on cognition and behaviour; Decreased lung function, Asthma induction, Worsening of Cystic Fibrosis In Children: Adverse impact on cognition and behaviour; Decreased lung function, Asthma induction, Worsening of Cystic Fibrosis Second hand smoke exposure causes 1100 to 7800 deaths/yr in Canada.

38 Ontario Tobacco Research Unit California Air Resources Board Report (2005) Updates 1997 Report Updates 1997 Report Confirms previous report findings Confirms previous report findings New Findings: New Findings: Paternal smoking causes childhood cancer Paternal smoking causes childhood cancer SHS is a cause of Breast Cancer in pre-menopausal women SHS is a cause of Breast Cancer in pre-menopausal women SHS may increase risk of Cervical Cancer, Bladder Cancer SHS may increase risk of Cervical Cancer, Bladder Cancer

39 Ontario Tobacco Research Unit Surgeon General’s Report (2006) NO RISK-FREE LEVEL OF EXPOSURE TO SECONDHAND SMOKE NO RISK-FREE LEVEL OF EXPOSURE TO SECONDHAND SMOKE SHS causes premature death and disease in children and adult nonsmokers SHS causes premature death and disease in children and adult nonsmokers SHS exposure has IMMEDIATE adverse effects on CV system and causes CHD and lung cancer SHS exposure has IMMEDIATE adverse effects on CV system and causes CHD and lung cancer Similar findings to CAL EPA except breast cancer (“evidence is suggestive..”) Similar findings to CAL EPA except breast cancer (“evidence is suggestive..”)

40 Ontario Tobacco Research Unit Breast Cancer and Second-hand Smoke Inconsistent findings on breast cancer and tobacco smoke. Inconsistent findings on breast cancer and tobacco smoke California ARB Report 2005 California ARB Report   “…consistent with causality in younger, primarily pre- menopausal women.” 2006 Surgeon General’s Report 2006 Surgeon General’s Report   “…suggestive but not sufficient to infer a causal relationship between second-hand smoke and breast cancer” 2009 IARC Report 2009 IARC Report  Supports findings of SGR 2014 SGR 2014 SGR  Same as 2006 report for breast cancer

41 Ontario Tobacco Research Unit Expert Panel on Tobacco Smoke and Breast Cancer Risk (2009) Expert Panel on Tobacco Smoke and Breast Cancer Risk (2009)Findings Relationship between SHS and breast cancer in younger, primarily pre-menopausal women is consistent with causality Evidence is considered insufficient to pass judgment on SHS and post-menopausal breast cancer.

42 Ontario Tobacco Research Unit Other Health Effects of SHS 20-30% increase in risk of stroke 20-30% increase in risk of stroke Smoke free policies reduce risk of coronary events among adults under 65 yrs Smoke free policies reduce risk of coronary events among adults under 65 yrs SF policies may reduce risk of CV events SF policies may reduce risk of CV events

43 Ontario Tobacco Research Unit Methodological Issues in Establishing Causation Too few studies that measured SHS exposure Too few studies that measured SHS exposure Exposure measures not always specific to site or include childhood Exposure measures not always specific to site or include childhood Too few disease cases to find significant relationships Too few disease cases to find significant relationships Exposure data collected recently Exposure data collected recently For some diseases, may be threshold effect rather than dose response For some diseases, may be threshold effect rather than dose response

44 Ontario Tobacco Research Unit New Research on SHS Exposure Substantial exposures occur indoors Substantial exposures occur indoors Smoke can travel in multi-unit dwellings Smoke can travel in multi-unit dwellings Even when mother smokes outdoors, child still has significant exposure Even when mother smokes outdoors, child still has significant exposure Outdoor exposure can be equally hazardous Outdoor exposure can be equally hazardous 1-2 metres heaviest exposure 1-2 metres heaviest exposure 8-9 metres required for protection 8-9 metres required for protection Eliminating awnings and umbrellas may not make a difference Eliminating awnings and umbrellas may not make a difference

45 Ontario Tobacco Research Unit

46 Hookah & Waterpipe Smoking Variability of nicotine content in tobacco hookah Variability of nicotine content in tobacco hookah Waterpipe smoking sessions (20-80 minutes) last longer than smoking a single cigarette (5-7 mins) Waterpipe smoking sessions (20-80 minutes) last longer than smoking a single cigarette (5-7 mins) Greater volume of inhaled smoke during waterpipe session Greater volume of inhaled smoke during waterpipe session

47 Ontario Tobacco Research Unit Waterpipe Smoke is Toxic High levels of fine particulate matter, as much as cigarette smoking High levels of fine particulate matter, as much as cigarette smoking More carbon monoxide in the blood More carbon monoxide in the blood More smoke exposure than cigarettes More smoke exposure than cigarettes Possibly more nicotine exposure than cigarettes Possibly more nicotine exposure than cigarettes

48 Ontario Tobacco Research Unit Waterpipe Secondhand Smoke Waterpipe smoke includes charcoal & tobacco smoke Waterpipe smoke includes charcoal & tobacco smoke Typical 1 hour session likely generates carcinogens & toxicants times the amount in cigarette smoke (equivalent of 2-10 cigarettes) Typical 1 hour session likely generates carcinogens & toxicants times the amount in cigarette smoke (equivalent of 2-10 cigarettes) Indoor air quality in hookah bars show high levels of CO Indoor air quality in hookah bars show high levels of CO

49 Ontario Tobacco Research Unit Health Effects of Waterpipe Smoke Toxicants Waterpipe sidestream smoke vs. cigarette sidestream smoke (from a single session) emits approximately: 4 x PAHs – causes cancer 4 x PAHs – causes cancer 4 x VAs – causes lung disease 4 x VAs – causes lung disease 30 x CO – contributes to CVD 30 x CO – contributes to CVD Nicotine – causes dependence Nicotine – causes dependence

50 Ontario Tobacco Research Unit Serious Health Effects Respiratory illness (Likely cause of COPD) Respiratory illness (Likely cause of COPD) Reduced lung function Reduced lung function Low birth-weight Low birth-weight Periodontal disease Periodontal disease Cardiovascular disease Cardiovascular disease Nicotine/tobacco dependence Nicotine/tobacco dependence Lung cancer Lung cancer Infectious diseases transmitted by shared hookah Infectious diseases transmitted by shared hookah

51 Ontario Tobacco Research Unit Thirdhand Smoke What remains in air, on surfaces and people after cigarette is extinguished What remains in air, on surfaces and people after cigarette is extinguished Off-gassing in indoor environments can continue for weeks, months, years Off-gassing in indoor environments can continue for weeks, months, years Outdoor contaminants can be carried indoors and transferred to infants & others Outdoor contaminants can be carried indoors and transferred to infants & others Causes DNA damage in humans Causes DNA damage in humans

52 Ontario Tobacco Research Unit E-Cigarettes Increasing use, especially among youth and young adults despite HC ban Increasing use, especially among youth and young adults despite HC ban Exposures and risks not fully established: not just water vapour Exposures and risks not fully established: not just water vapour No confirmed evidence for impact on cessation beyond regular NRT No confirmed evidence for impact on cessation beyond regular NRT Concerns that use will undermine smoking bans, increase social exposure and lead to increases in all tobacco and nicotine use Concerns that use will undermine smoking bans, increase social exposure and lead to increases in all tobacco and nicotine use

53 Ontario Tobacco Research Unit Conclusion Smoking and tobacco smoke exposure have major health effects and a corresponding burden of health and human costs Smoking and tobacco smoke exposure have major health effects and a corresponding burden of health and human costs Efforts to eliminate smoking and smoke exposure will have a major impact on reducing exposure Efforts to eliminate smoking and smoke exposure will have a major impact on reducing exposure Tobacco industry a major threat to reducing or eliminating tobacco use and exposure Tobacco industry a major threat to reducing or eliminating tobacco use and exposure Nevertheless, we have many ways to reduce the health burden of tobacco Nevertheless, we have many ways to reduce the health burden of tobacco


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