Department of Epidemiology

Secondhand Smoke (SHS):

The Facts
Jonathan M. Samet, MD, MS
Institute for Global Tobacco Control

December 15, 2004

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 Tobacco
• Sudden and • Slow and accepted
dreaded • Delayed global
• Immediate global response
response • Billions of smokers and
• Thousands of cases millions of deaths
and hundreds of • Spread by multi-
deaths national corporations
• Spread by contact
and travel
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
Tipping Monogra
Filter m Cigarette paper
paper
Ink

Ventilation Plugwra Cigarette Paper Tobacco and

holes p
Adhesive additives
Paper
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

Source: JM Samet
SHS OR ETS?

Some Terminology
•Active smoking
•Passive smoking
•Involuntary smoking

SHS or ETS
•SHS preferred
•ETS originated
with industry
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?
 Basic Concepts
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 exposure depends on places
Model: where time spent
Personal Exposure to CO Across a Day

(Klepeis, 1999)
(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
ng/mL 0.2
0.2

Relative decline - greater than 75%

0.15

0.1

0.05
0.05

1988-91 1999

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

(Klepeis, 1999)
SHS Exposure

(Klepeis, 1999)
 Surveillance Of Secondhand
Tobacco Smoke In Latin America
Ana Navas Acien
Project Coordinator

Institute for Global Tobacco Tobacco Control Program

Control (IGTC)
Pan American Health Organization
Johns Hopkins Bloomberg School of (PAHO/WHO)
PH Baltimore, MD Washington DC

Director: Jonathan Samet Regional Advisor: Armando Peruga

 Nicotine monitoring

• Passive sampling of vapor-phase

nicotine

~ 120 monitors per country, 7-14 days

Nicotine filter
• 10% duplicates, 10% blanks (QC)

• Airborne nicotine concentration (µg/m3)

Gas-chromatograph
measured by gas-chromatography
 Hospitals – nicotine (µg/m3)
12

P75
P50
0 p25
Peru Chile Argentina Costa Rica Uruguay
N= 20 25 24 22 27
 Restaurants
N p50 p75 p90 mean (SD)
Area

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)

12

Non-smoking area
8

Peru Chile Argentina Costa Rica Uruguay

N= 15 13 8 15 14
City Government Buildings – nicotine (µg/m3)

12

0 P75
P50
Peru Chile Argentina Costa Rica Uruguay p25

N= 19 20 16 18 21
What are the health
effects of SHS
exposure?
 Hirayama’s Pioneering 1981 Paper:
SHS and Lung Cancer in Japanese Women

BMJ 1981 Jan

17;282(6259):183-5
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
 SHS and Lung Cancer:
Meta-analysis of Female Data

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

10
Relative risk

0.1

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

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
IARC 2002

•Involuntary
smoking (exposure
to secondhand or
'environmental'
tobacco smoke) is
carcinogenic to
humans (Group 1).
 Adverse Effects of Exposure
to Secondhand Tobacco Smoke

Children

Adults
Can Exposures to SHS
be Reduced?
Reducing Exposure to SHS

Control source
- Reduce smoking
Change the source
Separate smokers and nonsmokers
Increase ventilation
Use air cleaning
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.”
Alternative Products
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.
Establishing Smokefree Places

• Hospitals
• Public Places
• Workplaces
• Transportation
• Restaurants
• Bars
Benefits of Smokefree Workplaces
Benefits for Employees Benefits for Employer
 Creates safe and healthy
workplace  Increased worker
productivity
 Well planned and
carefully implemented  Reduces health care
effort can reduce smoking costs
among employees
 Reduces maintenance
 Clearly defined policy costs
leads to compliance
 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
Percent

70 68.6
63.0
60
Relative increase + 49.8%
50
45.8
40

30

20

10
3.0
0
1986 1992-93 1995-96 1998-99

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

1986 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
Change in smoke-free workplace policy coverage among
indoor American workers by type of worker
Self-respondents ages 15 years and older

Percent
76
1992-93 1995-96 1998-99
80 71.3

56.8
53.7
60 51.4 50.4
44.8

34.8
40
27.4

20

0
White collar Blue collar Service
 Smokers’ Beliefs About
Where Smoking Should Never Be Allowed
90
US minus CA
80 78.7
CA

70
% S m o k e rs

60 58.1
58.3 57.7
54.8

50
47.4

42.0
40
37.4

30 31.9

20
16.7

10 10.5

6.2

0
Restaurants Hospitals Work Areas Bars Sports Malls
Arenas

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
nonsmokers in U.S. from SHS
Thousands
5 Congress imposes temporary
ban on smoking aboard flights
of less than 2 hrs duration
1988
4 CAB requires smoking CalEPA report links
and nonsmoking SHS to CHD & SIDS
seating deaths in 1997
on airlines. July 1973
3 1st epidemiological
SG Jesse Steinfeld studies published
calls for linking ETS with
nonsmokers bill of lung cancer Jan
2 rights Jan. 1971 1981 NAS (Nov 1986) and
Surgeon General (Dec. EPA issues major
ICC restricts 1986) release major report on SHS in
smoking to rear reviews on health adults and children
1 20% of interstate effects of ETS Jan 1993
buses.
Congress eliminates smoking aboard
virtually all commercial airlines
0 Feb 1991
1970 1975 1980 1985 1990 1995 2000

1st report to review MN passes 1st law NCI publishes airline study
requiring employers to demonstrates nonsmokers seated in
ETS effects Jan. 1972
protect nonsmokers June nonsmoking section significantly
1975 exposed to ETS Feb. 1989
Philip Morris Document (1998): Impact of smoke-
free workplace policies on Cessation
Smokers facing
workplace
restrictions have a
84% higher quit rate
than average
10% industry decline if
smoking was banned in
all workplaces
Anticipate a 74% increase
in quitting rate 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)

 BMJ VOLUME 326 17
MAY 2003
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)
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.ht
ml
• http://www.who.int/tobacco/en/
• http://www.cdc.gov/tobacco/sgr/sgr
_2004/chapters.htm