1. Determining Exposure to Secondhand Smoke Richard D. Hurt MD Professor of Medicine, College of Medicine Director, Nicotine Dependence Center Mayo Clinic

2. 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.

3. Group A Carcinogens Arsenic Arsenic Asbestos Asbestos Benzene Benzene Environmental tobacco smoke Environmental tobacco smoke Radon Radon Vinyl chloride Vinyl chloride

4. Tobacco Smoke Constituents Arsenic Arsenic Benzene Benzene Benzo[a]pyrene Benzo[a]pyrene Cadmium Cadmium Chromium V1 Chromium V1 Cresol Cresol Formaldehyde Formaldehyde Lead Lead Nitrosamines Nitrosamines Phenol Phenol Polycyclic aromatic hydrocarbonsPolycyclic aromatic hydrocarbons Vinyl chloride Vinyl chloride Polonium 210 Polonium 210 Nov. 1, 2006 Polonium 210 Polonium 210 Alexander Litvinenko Nov. 22, 2006

5. 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 1.01-1.31) 1.37 CVD mortality (CI 1.06-1.78) Smoking at work: 1.79 lung cancer mortality (CI 1.09-2.93) Wen W, BMJ 333:376, 2006

6. California EPA Report on ETS – 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 - 300,000 Otitis Media Office Visits 790,000 SIDS430 Adults Cardiac Deaths 46,000 (22,700-69,600) Lung Cancer Deaths 3,400

7. 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

8. SHS Exposure and Urine Cotinine

9. Passive Smoking 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 Passive smoke exposure x 5 minutes vs. 1 cigarette vs. sham smoking Passive smoke 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

11. 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

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

13. Thirdhand Smoke Tobacco Specific Nitrosamines- NNN, NNK, NNA all potent carcinogens Tobacco Specific Nitrosamines- NNN, NNK, NNA all potent carcinogens Residual nicotine + ambient air nitrous oxide TSNAs Residual nicotine + ambient air nitrous oxide TSNAs Nicotine and TSNAs measured in vehicles and homes of smokers Nicotine and TSNAs measured in vehicles and homes of smokers Nicotine builds up (especially in carpet) with repeated exposure and persists for weeks or months on indoor surfaces Nicotine builds up (especially in carpet) with repeated exposure and persists for weeks or months on indoor surfaces TSNA residue on hair, cotton, skin, dust, furniture range from ng/mL to µg/mL TSNA residue on hair, cotton, skin, dust, furniture range from ng/mL to µg/mL Sleiman M et al PNAS 107:6576, 2010

15. NNAL in Infants Exposed to Tobacco Smoke 47% of 144 infants had detectable urine NNAL and 98% had detectable urine cotinine 47% of 144 infants had detectable urine NNAL and 98% had detectable urine cotinine 82% of the mothers were daily smokers and 72% lived in household that included other smokers 82% of the mothers were daily smokers and 72% lived in household that included other smokers Mean cigarettes smoked/week was significantly higher in infants where NNAL was detectable Mean cigarettes smoked/week was significantly higher in infants where NNAL was detectable First study to show carcinogen (NNK) uptake by infants exposed to tobacco smoke First study to show carcinogen (NNK) uptake by infants exposed to tobacco smoke Hecht SS, et al. Cancer Epid Biomarkers Prev; 15:988-92, 2006

16. Questions to Determine SHS Exposure Mayo Clinic Lung Cancer Survey Are you regularly exposed to secondhand tobacco smoke? Are you regularly exposed to secondhand tobacco smoke? If so, indicate the amount of secondhand smoke exposure by estimating the number of cigarettes, cigars or pipe smoked around you per day. If so, indicate the amount of secondhand smoke exposure by estimating the number of cigarettes, cigars or pipe smoked around you per day.

17. Questions to Determine SHS Exposure Global Adult Tobacco Survey How often does anyone smoke in your home? How often does anyone smoke in your home? Daily Daily Weekly Weekly Monthly Monthly Less than Monthly Less than Monthly Never Never In the past 30 days, did anyone smoke in indoor areas where you work? In the past 30 days, did anyone smoke in indoor areas where you work?

18. Questions to Determine SHS Exposure CDC Adult Tobacco Survey Is smoking permitted in your home? Is smoking permitted in your home? No, not anywhere or at any time. No, not anywhere or at any time. Allowed some places or times. Allowed some places or times. Yes, allowed any where at any time. Yes, allowed any where at any time. Number of days smoking occurred in home during last week. Number of days smoking occurred in home during last week. None None 1-2 1-2 3-6 3-6 7

19. 19 Create and mobilize a global network of healthcare providers and organizations dedicated to advancing effective tobacco dependence treatment and advocating for effective tobacco control policy. Global Bridges Mission

20. 20 Build a network… Create opportunities to share treatment and advocacy expertise among network members within and across regions Provide training… State-of-the-art, evidence-based training in tobacco dependence treatment and advocacy Article 14 implementation… Facilitate the implementation of FCTC Article 14 in every nation Sustain the mission… Ensure the long-term financial sustainability of the initiative Primary Aims

21. 21 Global Bridges Regional Structure The world will be divided into 7 regions corresponding to the WHO regional divisions: -Africa-Western Pacific -Europe-Americas (South) -South East Asia-Americas (North) -Eastern Mediterranean Develop and execute a regional plan in collaboration with the Global Bridges Management Team.

22. 22 Clinton Global Initiative Created in 2005 by President Bill Clinton to help turn good intentions into real actions and results. Convenes over 1,000 global leaders to devise and implement innovative solutions to some of the worlds most pressing problems CGI members make commitments to improve the lives of people across the globe

23. 23 Global Smoke-free Worksite Challenge Winter meetings of CGI participants helps implement commitments and also generate new ideas Ask all CGI members to develop and implement smoke-free worksites Leaders of the new commitment: Mayo Clinic, ACS, J&J, DHSS, Campaign for Tobacco-free Kids

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28. 28 http:// www.clintonglobalinitiative.org/ourmeetings/2011/meeting_annual_multimedia_player.asp?id=53