SHS-rev-2

Health Effects of Tobacco Secondhand Smoke
[SHS]: focus on Children Health
A Review of the Evidence
Center for the Study of International Medical Policies and Practices
[CSIMPP]
Arnauld Nicogossian, MD, FACPM, FACP
School of Policy, Government and International Affairs,
George Mason University
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Disclosure/Disclaimer
 No Competing Conflicts of Interest or Financial
Support for this Activity
 Any opinions, findings, conclusions or
recommendations expressed in this presentation
are those of the author [s] and do not
necessarily reflect the views of the George
Mason University.
 The author is the Director of the WMA
Collaborating Center on Microbial Resistance
and Development of Public [Health] Policy.
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OUTLINE
 Learning Objectives
 Overview
 Types of Smoking Implements
 Definitions
 Statements by WMA and WHO
 Epidemiology
 Health Effects of SHS
 Third Hand Smoke
 Prevention and Control of Tobacco Smoke Exposure
 Conclusions
 Points to Remember 4Revision 2
Learning Objectives
1. Understand the strength of the evidence supporting
the health effects of tobacco second hand smoke
(TSHS) in children, and
2. Review the efficacy of interventions, including
policies and legislations, designed to minimize TSHS
exposures of infants and children.
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Overview
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Tobacco Smoke Delivery Systems and
Nicotine
Most Common Tobacco
Implements
Major Nicotine Health
Hazards
 Nicotine is the primary addicting
drug in cigarettes. When
combined with other combustion
by-products it can result in:
 Cardiovascular disease.
 Pulmonary chronic disorders.
 Multi-organ cancer, and
 Premature births and low birth weight
babies and is harmful to developing
brains in women who smoke during
pregnancy.
 There is no safe level of exposure
to SHS.
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Definitions
 SHS Exposure can result from
 Mainstream smoke – the smoke that is exhaled from the smoker’s
lungs, and
 Sidestream smoke – the smoke from the burning end of a tobacco
product.
 Third Hand Smoke [TSH] exposure results from the deposition of
nicotine on personal items and other surfaces.
 About 15% of SHS exposures is mainstream and 85% is sidestream
though the composition of toxins in both sources is similar
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WMA [2006] and WHO [2009]
World Medical Association
 Recognizing the abundant evidence linking
adverse health outcomes and exposure to
second-hand smoke; and
Noting that despite this new evidence many
countries still allow smoking in public areas;
 The World Medical Association:
• Congratulates the French government and
French physicians for the introduction of
legislation that would ban smoking in public
areas; and
 Urges other National Medical Associations to
advocate for similar legislative changes in their
own countries if such legislation does not exist.
World Health Organization
 Second-hand smoke
accounts for one in 10 tobacco-
related deaths.
 Creating 100% smoke-free
environments is the only way
to protect people from the
harmful effects of second-hand
tobacco smoke.
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Epidemiology
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Tobacco Smoke Affects Most Body
Organs [CDC. US/Gov.]
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SHS Health Effects Sources and Strength of Evidence
[see Review Document]
In Adults [Good Evidence]
 Coronary heart disease (Japuntich et
al. 2015)
 Stroke (Olasky et al. 2012)
 Dementia (Barnes et al. 2010).
 Breast cancer (WHO 2007)
 Chronic respiratory illnesses (WHO
2007)
 Decline in pulmonary function (WHO
2007)
In Children [Fair to Good
Evidence]
1. Sudden Infant Death Syndrome [USSG
2006 Report].
2. Low Birth Weight [USSG 2006 Report].
3. Pulmonary and Cardiovascular
developmental risks [Kabir et al. 2009,
Tanski and Wilson 2012].
4. Otitis media [Muller 2007].
5. Neurological and mental disorders [Rao et
al. 2009, Brooks et al. 2011, Evlampidou
et al. 2015, Padron et al. 2015].
6. Lifelong risk of obesity [McConnell et al.
2015].
[Evidence for detrimental effects from SHS exposure
in children and infants is expanding]
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Health Effects fromThird Hand Smoke [THS]
from Tobacco
 Growing evidence for health effects from the remaining tobacco residues
deposited on surfaces, smokers’ clothes and hair.
 Nonsmokers who are exposed to such environments are considered to be
victims of third-hand tobacco smoking (THS) [Escoffery et al. 2013].
 Trace levels of nicotine remains in the air, dust, and surfaces of
residential settings which can be harmful especially to children.
 Nonsmokers who reside in homes previously occupied by smokers have
demonstrated elevated levels of nicotine on hands and in urine compared
to those residing in homes where no one has smoked [Matt et al. 2011].
 The role of particulate in the smoke such as polycyclic aromatic
hydrocarbons (PAHs), from incomplete combustion of carbon-
containing materials, is suspected to be carcinogenic [Fleming et al.
2012].
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 Prevention and Control of Tobacco Smoke
Exposure
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Control Measures
WHO FCTC [Introduced 1993]
 Measures relating to reducing the demand for
tobacco
• Price and tax measures
• Protection from exposure to environmental tobacco smoke
• Regulation and disclosure of the contents of tobacco
products
• Packaging and labelling
• Education, communication, training, and public awareness
• Comprehensive ban and restriction on tobacco advertising,
promotion, and sponsorship
• Tobacco dependence and cessation measures
 Measures relating to reducing the supply of
tobacco
• Elimination of the illicit trade of tobacco products
• Restriction of sales to and by minors
• Support for economically viable alternatives for growers
Implementing FCTC [WHO 2011]
 Smoking bans in bars and restaurants have been
enacted in
 Norway,
 New Zealand,
 England, Scotland, Wales, Northern Ireland,
 Italy,
 Spain,
 Malta,
 USA, and
 France.
 By 2010, 31 countries have taken steps to
provide the highest level of protection against
SHS for their citizens.
 Has been signed by168 countries and is legally
binding in 180 ratifying countries, and countries
meet the best practice for pictorial warnings
[2015].
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Source; Kenji Shibuya et al. BMJ. 2003 Jul
19; 327(7407): 154–157
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Control and Interventions
[ADVERTISING, PROMOTION AND SPONSRSHIP POLICIES, BY WHO REGION, 2014]
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As at December 2014, only 29 WHO Member States had comprehensive bans on tobacco advertising, promotion and
sponsorship
(% of Countries categorized by WHO Regions 2014)
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Interventions/Policies
WHO 2006
 MPOWER Principles
1. Monitoring tobacco use and
prevention policies.
2. Protecting people from tobacco
smoke.
3. Offering help to quit tobacco use.
4. Warning about the dangers of tobacco
5. Enforcing bans on tobacco
advertising, promotion and
sponsorship, and
6. Raising taxes on tobacco.
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Article 11 of FCTC
 Article 11 of the WHO FCTC
requires that health warning labels on
tobacco packaging (to):
 Be approved by the competent
national authority;
 Should cover 50% or more of the
principal pack display areas, but
should be no less than 30%;
 Be large, clear, visible and legible;
 Not use misleading terms like “light”
and “mild”;
 Be rotated periodically to remain
fresh and novel to consumers;
 Display information on relevant
constituents and emissions of tobacco
products as defined by national
authorities;
 Appear in the principle language(s)
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US FDA proposed graphic warning labels on tobacco
products packages. On august 24, 2012 the US Court
of Appeals for the District of Columbia issued a
ruling to block the use of graphic warning labels on
all cigarette packages, upholding a ruling by the US
District Court on November 7, 2011. Further court
rulings is expected in 2016.
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On November 12, 2015, the U.S. Department of Housing and Urban
Development (HUD) issued its proposed rule that will require 3,100
public housing agencies across the country to go smoke free. Public
housing agencies will need to implement smoke free policies in their
developments within 18 months of the final rule. This equates to
over 1 million people protected from secondhand smoke in their
homes, including 760,000 children
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Use of Mass Media Campaigns
Strength of Evidence
1. Mass media campaigns and financial support have also been explored as ways to encourage smoking cessation.
Such campaigns can be effective when combined with other interventions but their effects on smoke cessation alone
are difficult to determine. In April 2013, the Community Preventive Services Task Force, established by the US
Department of Health and Human Services (USDHHS), an equivalent of a ministry of health, issued a statement
recommending mass-reach health interventions. Their systematic review of over 90 studies showed strong evidence
of effectiveness in
Decreasing the prevalence,
Increasing quit rates, and
Decreasing smoking uptakes (Community Preventive Services Task Force 2013).
2. A review of eleven trials involving financial interventions suggests that provision of full financial coverage for
cessation treatments significantly increased the intention to and success rates of quitting compared to interventions
without financial support (Reda et al. 2012).
3. Antismoking legislation is effective based on the systematic review of 50 studies in 5 countries showed consistent
evidence of reduction of SHS exposure in workplaces, restaurants, bars and in public places (Callinan et al. 2010).
4. Interventions to encourage smoking cessation and reduce exposure to SHS vary widely and involve many
stakeholders and components. Due to the lack of standard definitions of components such as smoking, smokers, and
quit attempts as well as the lack of sufficient number of similar interventions, there is, to date, little evidence of
effectiveness of one type of intervention over others.
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Conclusions
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1. Robust evidence links tobacco use to respiratory and cardiovascular diseases, including cancer.
2. Good evidence links SHS tobacco exposures to medical problems in infants, children and
adults.
3. SHS tobacco exposures in private place continues to be a major health threat to pregnant
women, infants and children, and in several US litigation case were labeled as child neglect
[rarely as abuse].
4. Developing market economy countries continue to have higher tobacco use and SHS exposure
levels.
5. According to the American Cancer Society (ACS 2015) the estimated health care costs for
tobacco use between 2000 and 2012 in billions of dollars, in several countries, amounted to:
a. USA 133
b. France 16.6
c. United Kingdom 9.5
d. China 6.2 (conservative estimates)
e. Canada 2.8
6. There is no single effective preventive intervention, but rather a combination of measures such
as smoking bans, taxations, education, systematic and sustained outreach campaigns, package
labeling, and improved health literacy.
7. Several countries including US are considering legislations to prohibit smoking in private
spaces
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Points To Remember
[ABCE²]
1. Avoid Exposure with
focus on maternal and
child health
2. Best practices
supported by evidence
3. Consistent
administrative policies
and legislations
4. Enforcing policies
based on the
International
Conventions
5. Education
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Schools of Public Policy
Professional Schools
Academic Health Centers
Consumers
Food Producers
Policy Makers
Advocates
Societies
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