 2011 Johns Hopkins Bloomberg School of Public Health Jonathan M. Samet, MD, MS Director, USC Institute for Global Health Professor and Flora L. Thornton Chair, Department of Preventive Medicine Keck School of Medicine Smoking and Health: An Update

 2011 Johns Hopkins Bloomberg School of Public Health Global Tobacco Epidemic State of the global tobacco epidemic and an update on the health effects of smoking 2

 2011 Johns Hopkins Bloomberg School of Public Health Prevalence of Current Cigarette Smoking *GATS = Global Adult Tobacco Survey 3

 2011 Johns Hopkins Bloomberg School of Public Health The 2010 Report of the U.S. Surgeon General Reviews mechanisms by which smoking causes disease Includes findings from human, animal, and laboratory studies Evidence important for causation, prevention, diagnosis, and treatment 4 Text and image source: USDHHS. (2010).

 2011 Johns Hopkins Bloomberg School of Public Health SGR 2010: Major Conclusions Source: USDHHS. (2010). 5

 2011 Johns Hopkins Bloomberg School of Public Health SGR 2010: Summary on Genetics of Nicotine Addiction Source: USDHHS. (2010). 6

 2011 Johns Hopkins Bloomberg School of Public Health Emerging Information on the Health Effects of Smoking Tuberculosis Breast cancer Diabetes mellitus 7

 2011 Johns Hopkins Bloomberg School of Public Health Smoking and Tuberculosis 8

 2011 Johns Hopkins Bloomberg School of Public Health Smoking and Tuberculosis 9

 2011 Johns Hopkins Bloomberg School of Public Health Risk of Latent TB Infection for Smoking vs. Nonsmoking Image source: (2007). PLoS Med, 4:e20 10

 2011 Johns Hopkins Bloomberg School of Public Health Risk of Clinical TB for Current Smoking vs. Nonsmoking Image source: (2007). PLoS Med, 4:e20 11

 2011 Johns Hopkins Bloomberg School of Public Health Risk of TB Mortality for Smoking vs. Nonsmoking Image source: (2007). PLoS Med, 4:e20 12

 2011 Johns Hopkins Bloomberg School of Public Health Smoking and Tuberculosis 13

 2011 Johns Hopkins Bloomberg School of Public Health Smoking and Tuberculosis Mortality risk ratio* (99% CI) Smoking- attributable risk Men2.3 ( )38 % Women3.0 ( )9 % *RR comparing smokers to nonsmokers, adjusted for age, education, and alcohol Deaths due to tuberculosis among Indian adults ages years Estimated excess smoking-associated deaths among Indian adults in 2010 Number of excess TB deaths Men120,000 of 315,000 Women14,000 of 155,000 Source: Jha et al. (2008). NEJM, 358,

 2011 Johns Hopkins Bloomberg School of Public Health Tobacco Smoking/SHS Exposure and Breast Cancer Risk SourceYearStudies reviewedConclusions International Agency for Research on Cancer (IARC) 2004 Active smoking: 36 case-control studies, 8 cohort studies, 1 large pooled analysis Secondhand smoke: 10 case- control studies, 5 cohort studies Active smoking: There is evidence suggesting lack of carcinogenicity of tobacco smoking in humans for cancers of the female breast and endometrium. Secondhand smoke: The collective evidence on breast cancer risk associated with involuntary exposure of never smokers to tobacco smoke is inconsistent. U.S. Surgeon General’s Report case-control studies, 5 cohort studies Active smoking: The evidence is suggestive of no causal relationship between active smoking and breast cancer. Subgroups of women cannot yet be reliably identified who are at an increased risk of breast cancer because of smoking, compared with the general population of women. Whether women who are at a very high risk of breast cancer because of mutations in BRCA1 or BRCA2 genes can lower their risks by smoking has not been established. U.S. Surgeon General’s Report case-control studies, 7 cohort studies Secondhand smoke: The evidence is suggestive but not sufficient to infer a causal relationship between SHS and breast cancer. 15

 2011 Johns Hopkins Bloomberg School of Public Health Tobacco Smoking/SHS Exposure and Breast Cancer Risk SourceYearStudies reviewedConclusions Cal/EPA studies (including 3 meta- analyses) Secondhand smoke: Human epidemiological studies, supported by the fact that at least 20 of the chemical constituents of ETS are mammary carcinogens, provide evidence consistent with a causal association between ETS exposure and breast cancer in younger primarily premenopausal women. There is little, if any, evidence of an increase in breast cancer risk in older primarily postmenopausal women. Canadian Expert Panel on Tobacco Smoke and Breast Cancer 2009 Active smoking: 7 reviews and 4 meta-analyses Secondhand smoke: 5 reviews and 4 meta- analyses Genetics and active smoking: 3 meta-analyses Active smoking: Based on the weight of evidence from epidemiologic and toxicological studies and understanding of biological mechanisms, the associations between active smoking and both pre- and postmenopausal breast cancer are consistent with causality. Secondhand smoke: The association between SHS and breast cancer in younger, primarily premenopausal women who have never smoked is consistent with causality. The evidence is considered insufficient to pass judgment on SHS and postmenopausal breast cancer. 16

 2011 Johns Hopkins Bloomberg School of Public Health Smoking and Diabetes Image source: Willi et al. (2007). JAMA, 298,

 2011 Johns Hopkins Bloomberg School of Public Health Smoking and Diabetes Image source: Willi et. al. (2007). JAMA, 298,

 2011 Johns Hopkins Bloomberg School of Public Health Menthol Cigarettes 19 A report of the FDA’s Tobacco Products Scientific Advisory Committee (TPSAC)

 2011 Johns Hopkins Bloomberg School of Public Health Menthol Cigarettes Menthol is an organic compound (a naturally occurring monocyclic terpene alcohol), either derived from natural sources or synthesized, widely used in consumer and medicinal products Pharmacologically, menthol in cigarette smoke has a cooling effect that may facilitate deeper inhalation and mask the irritation by nicotine and other smoke components Menthol is present in most cigarettes in the United States, and in about 30% of cigarettes it is present in high enough concentration to make menthol the characterizing flavor 20

 2011 Johns Hopkins Bloomberg School of Public Health Menthol Cigarettes The FDA is charged with addressing the impact of the use of menthol in cigarettes on the public health  Its scientific committee developed a report on this topic, released in March 2011 Menthol cigarettes are not common worldwide, but products are being developed 21

 2011 Johns Hopkins Bloomberg School of Public Health Menthol: Possible Effects on Public Health Image source: Tobacco Products Scientific Advisory Committee (TPSAC), FDA

 2011 Johns Hopkins Bloomberg School of Public Health TPSAC Conclusions: Based on the conclusions to the nine questions, TPSAC provides the following general conclusions: Menthol cigarettes have an adverse impact on public health in the United States There are no public health benefits of menthol compared to non-menthol cigarettes 23

 2011 Johns Hopkins Bloomberg School of Public Health TPSAC’s Recommendation to FDA Removal of menthol cigarettes from the marketplace would benefit public health in the United States 24