Determining Exposure to Secondhand Determining Exposure to Secondhand Smoke Smoke

Richard D. Hurt MDRichard D. Hurt MD

Professor of Medicine, College Professor of Medicine, College of Medicineof Medicine

Director, Nicotine Dependence Director, Nicotine Dependence CenterCenter

Mayo ClinicMayo Clinic

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,

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.

and finally, of late years, hospital ward and sanatorium, even when and where patients seriously ill from respiratory diseases are under treatment.

Group A CarcinogensGroup A Carcinogens

• ArsenicArsenic

• AsbestosAsbestos

• BenzeneBenzene

• Environmental tobacco smokeEnvironmental tobacco smoke

• RadonRadon

• Vinyl chlorideVinyl chloride

Tobacco Smoke ConstituentsTobacco Smoke Constituents

• ArsenicArsenic

• BenzeneBenzene

• Benzo[a]pyreneBenzo[a]pyrene

• CadmiumCadmium

• Chromium V1Chromium V1

• CresolCresol

• FormaldehydeFormaldehyde• FormaldehydeFormaldehyde

• LeadLead

• NitrosaminesNitrosamines

• PhenolPhenol

• Polycyclic aromatic Polycyclic aromatic hydrocarbons hydrocarbons

• Vinyl chlorideVinyl chloride

• Polonium 210Polonium 210Nov. 1, 2006 • Polonium 210Polonium 210Alexander Litvinenko

Nov. 22, 2006

Mortality in Non-Smoking Chinese WomenMortality in Non-Smoking Chinese WomenSecondhand SmokeSecondhand Smoke

Prospective cohort of 72,829 non-smoking womenProspective cohort of 72,829 non-smoking women

Secondhand smoke exposure from spouses, work and Secondhand smoke exposure from spouses, work and early lifeearly life

All cause and specific cause (cancer & CVD) mortalityAll cause and specific cause (cancer & CVD) mortality

Smoking spouses:Smoking spouses:

1.15 1.15 ↑ all cause mortality (CI 1.01-1.31)↑ all cause mortality (CI 1.01-1.31)

1.37 ↑ CVD mortality (CI 1.06-1.78)1.37 ↑ CVD mortality (CI 1.06-1.78)

Smoking at work:Smoking at work:

1.79 ↑ lung cancer mortality (CI 1.09-2.93)1.79 ↑ lung cancer mortality (CI 1.09-2.93)

Wen W, BMJ 333:376, 2006Wen W, BMJ 333:376, 2006

California EPA Report on ETS – 2006California EPA Report on ETS – 2006Excess Morbidity and Mortality in USAExcess Morbidity and Mortality in USA

PregnancyPregnancyLow birth weight infantsLow birth weight infants

Pre Term DeliveryPre Term Delivery

24,500 24,500

71,90071,900

ChildrenChildrenAsthma EpisodesAsthma Episodes 202,300202,300

Lower Respiratory IllnessLower Respiratory Illness 150,000 - 300,000150,000 - 300,000

Otitis Media Office VisitsOtitis Media Office Visits 790,000790,000

SIDSSIDS 430430

AdultsAdultsCardiac DeathsCardiac Deaths 46,000 (22,700-69,600)46,000 (22,700-69,600)

Lung Cancer DeathsLung Cancer Deaths 3,4003,400

SHS and Exacerbations of Asthma SHS and Exacerbations of Asthma in Childrenin Children

• 199 children with asthma199 children with asthma

• Parental report of ETS exposureParental report of ETS exposure

• Median urine cotinine 5.6, 13.1 and 55.8 with Median urine cotinine 5.6, 13.1 and 55.8 with no SHS exposure, mother or other persons, no SHS exposure, mother or other persons, mother and other personsmother and other persons

acute asthma exacerbations with acute asthma exacerbations with exposure exposure (RR 1.8 parent report & 1.7 by cotinine)(RR 1.8 parent report & 1.7 by cotinine)

FEVFEV11 with with exposure exposure

Chilmonczyk BA. NEJM 328:1665, 1993Chilmonczyk BA. NEJM 328:1665, 1993

SHS Exposure and Urine CotinineSHS Exposure and Urine CotinineC

oti

nin

e (n

g/m

L)

Co

tin

ine

(ng

/mL

)

Chilmonczyk BA. NEJM 328:1665, 1993Chilmonczyk BA. NEJM 328:1665, 1993

NoNoexposureexposure

Mother orMother orothers smokeothers smoke

Mother andMother andothers smokeothers smoke

1

10

100

1000

5.65.6

13.113.1

55.855.8

CP969217-3

Passive Smoking and Aortic FunctionPassive Smoking and Aortic Function

• 16 male nonsmokers and 32 smokers (active 16 male nonsmokers and 32 smokers (active or sham smoking) undergoing cardiac or sham smoking) undergoing cardiac catheterization for chest paincatheterization for chest pain

• Aortic catheter to measure pressure and Aortic catheter to measure pressure and diameterdiameter

• Passive smoke exposure x 5 minutes vs. Passive smoke exposure x 5 minutes vs. 1 cigarette vs. sham smoking1 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, 1998Stefanadis C. Ann Intern Med 128:426, 1998

SHS and Aortic Function in 11y/o’sSHS and Aortic Function in 11y/o’s

• Atherosclerosis prevention trial in Atherosclerosis prevention trial in 386 Finnish children 386 Finnish children

• Serum cotinine concentrations to Serum cotinine concentrations to measure SHS exposuremeasure SHS exposure

• Abdominal aorta ultrasound- Abdominal aorta ultrasound- stiffness index, elastic modulous, stiffness index, elastic modulous, and distensibilityand distensibility

• ↑↑ Aortic stiffness with higherAortic stiffness with higher cotinine cotinine

Kallio K et al Pediatrics 123:e267, 2009Kallio K et al Pediatrics 123:e267, 2009

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

Thirdhand SmokeThirdhand Smoke• Tobacco Specific Nitrosamines- NNN, NNK, Tobacco Specific Nitrosamines- NNN, NNK,

NNA all potent carcinogensNNA all potent carcinogens

• Residual nicotine + ambient air nitrous oxide Residual nicotine + ambient air nitrous oxide → TSNAs→ TSNAs

• Nicotine and TSNAs measured in vehicles and Nicotine and TSNAs measured in vehicles and homes of smokershomes of smokers

• Nicotine builds up (especially in carpet) with Nicotine builds up (especially in carpet) with repeated exposure and persists for weeks or repeated exposure and persists for weeks or months on indoor surfacesmonths on indoor surfaces

• TSNA residue on hair, cotton, skin, dust, TSNA residue on hair, cotton, skin, dust, furniture range from ng/mL to µg/mLfurniture range from ng/mL to µg/mLSleiman M et al PNAS 107:6576, 2010Sleiman M et al PNAS 107:6576, 2010

NNAL in Infants Exposed to Tobacco SmokeNNAL in Infants Exposed to Tobacco Smoke

• 47% of 144 infants had detectable urine NNAL 47% of 144 infants had detectable urine NNAL and 98% had detectable urine cotinineand 98% had detectable urine cotinine

• 82% of the mothers were daily smokers and 82% of the mothers were daily smokers and 72% lived in household that included other 72% lived in household that included other smokerssmokers

• Mean cigarettes smoked/week was Mean cigarettes smoked/week was significantly higher in infants where NNAL was significantly higher in infants where NNAL was detectabledetectable

• First study to show carcinogen (NNK) uptake First study to show carcinogen (NNK) uptake by infants exposed to tobacco smokeby infants exposed to tobacco smoke

Hecht SS, et al. Hecht SS, et al. Cancer Epid Biomarkers PrevCancer Epid Biomarkers Prev; 15:988-92, 2006; 15:988-92, 2006

Questions to Determine SHS ExposureQuestions to Determine SHS ExposureMayo Clinic Lung Cancer SurveyMayo Clinic Lung Cancer Survey

• Are you regularly exposed to Are you regularly exposed to secondhand tobacco smoke?secondhand tobacco smoke?

• If so, indicate the amount of If so, indicate the amount of secondhand smoke exposure by secondhand smoke exposure by estimating the number of cigarettes, estimating the number of cigarettes, cigars or pipe smoked around you cigars or pipe smoked around you per day.per day.

Questions to Determine SHS ExposureQuestions to Determine SHS ExposureGlobal Adult Tobacco SurveyGlobal Adult Tobacco Survey

• How often does anyone smoke in How often does anyone smoke in your home? your home?

• DailyDaily• WeeklyWeekly• MonthlyMonthly• Less than MonthlyLess than Monthly• NeverNever

• In the past 30 days, did anyone In the past 30 days, did anyone smoke in indoor areas where you smoke in indoor areas where you work?work?

Questions to Determine SHS ExposureQuestions to Determine SHS ExposureCDC Adult Tobacco SurveyCDC 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 Number of days smoking occurred in home during last week. home during last week.

• NoneNone• 1-21-2• 3-63-6• 77

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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

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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

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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.

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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 world’s most pressing problems

CGI members make commitments to improve the lives of people across the globe

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