WEBINAR: Secondhand Smoke: The Science and Big Tobacco's Smokescreen

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Webinar presented for Global Bridges on February 27, 2013 …

Webinar presented for Global Bridges on February 27, 2013
By Dr. Richard Hurt, Director of Mayo Clinic Nicotine Dependence Center

The science behind the harmful effects of tobacco smoke will be reviewed in detail, including results from Dr. Hiryama’s landmark study of female Japanese lung cancer patients who are non-smoking wives of smoking husbands, as well as the most recent study showing that smoke-free workplace laws are associated with a reduction in the incidence of acute myocardial infarctions.

The presentation also highlights Big Tobacco’s decades long public relations and media campaigns to deceive the public and create doubt and controversy about the harmful effects of secondhand smoke. These data come from previously secret tobacco industry documents made public as a result of the Minnesota Tobacco Trial of 1998 and the Department of Justice case that resulted in the conviction of Big Tobacco for violating the U.S. racketeering laws.

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  • 1. Global Bridges Accomplishments Since April 2011, Regional Partners have trained over 1575 HCPs from 53 countries Over 18000 person-hours of training, reaching thousands of patients Presented at national, regional, and global meetings with combined attendance of over 22,000 www.globalbridges.org launched in 6 languages 724 members have joined via website Active collaborations with ATTUD, treatobacco.net, Global Nurses Network, American Academy of Pediatrics, Global Smokefree Partnership, Hong Kong Dept of Health, INWAT, American Association of Anesthesiologists, and others
  • 2. Secondhand Smoke – The Science and Big Tobacco’s Smokescreen Richard D. Hurt MD Professor of Medicine, College of Medicine Director, Nicotine Dependence Center Mayo Clinic rhurt@mayo.edu
  • 3. Objectives• Be able to name at least 4 toxic chemicals found in secondhand smoke• Understand that as little as 5 minutes of exposure to SHS can have an adverse effect on the arterial endothelium• Recognize that smoke-free workplace laws reduce the rates of Acute Myocardial Infarction• Recognize Big Tobacco’s tactic of creating doubt
  • 4. Public Health Policies Cigarette Companies Hate the Most• Increase in cigarette taxes• Smoke-free workplace laws• Why?• ↓ cigarette consumption in continuing smokers• ↑ the chance of a smoker to stop• ↓ the chance of a young person starting to smoke
  • 5. …defend itself on three major fronts --litigation, politics, and public opinion.-- creating doubt about the health charge without actually denying it
  • 6. Lung Cancer Mortality and Smoking 40 Non-smoker wives of non-smoker Standardized mortality rate husbands 32.79 for lung cancer/100,000 Non-smoker wives of husbands 30 Cigarette with smoking habits smokers Women with smoking habits 20 Total 15.50 108,906 Non-smoker 10 8.70 Familial passive Non-smoker smoking (+) Familial passive smoking (-) 0 21,895 69,645 17,366 Population at enrollment CP969217-4Hirayama T. BMJ 282:183, 1981
  • 7. Dr. Adlkofer who is the Scientific Director ofthe German Verbandt, has committed himself tothe position that Lee and Hirayama are correctand Mantel and TI are wrong. They believe Hirayama is a good scientist andthat his nonsmoking wives publication wascorrect. He replied with a strong statement thatHirayama was correct, that the TI knew it andthat the TI published its statement aboutHirayama knowing that the work was correct.
  • 8. Dr. Takeshi Hirayama 1923-1995“The grandfatherof epidemiologyin Asia”- JudithMackay
  • 9. Mortality in Non-Smoking Chinese Women Secondhand SmokeProspective cohort of 72,829 non-smoking womenSecondhand smoke exposure from spouses, work and early lifeAll cause and specific cause (cancer & CVD) mortalitySmoking 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
  • 10. California EPA Report on SHS – 2006 Excess Morbidity and Mortality in USAPregnancyLow birth weight infants 24,500Pre Term Delivery 71,900ChildrenAsthma Episodes 202,300Lower Respiratory Illness 150,000 - 300,000Otitis Media Office Visits 790,000SIDS 430AdultsCardiac Deaths 46,000 (22,700-69,600)Lung Cancer Deaths 3,400
  • 11. SHS and Exacerbations of Asthma in Children • 199 children with asthma • 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 •  acute asthma exacerbations with  exposure (RR 1.8 parent report & 1.7 by cotinine) •  FEV1 with  exposureChilmonczyk BA. NEJM 328:1665, 1993
  • 12. SHS Exposure and Urine Cotinine 1000 Cotinine (ng/mL) 100 55.8 13.1 10 5.6 1 No Mother or Mother and exposure others smoke others smokeChilmonczyk BA. NEJM 328:1665, 1993 CP969217-3
  • 13. the rats resisted to the daily loading into the exposure tubes and continued to struggle inside the tubes right after the beginning of the the rats of the sidestream the rats continued to exposure. By and large, groups of the show shaggy fur and some pronounced respiratory sidestream groups reacted more vigorously 1 rat of the mainstream group,whistling the puffed symptoms characterized by 9 group. and rattling than those of the mainstream rats of sounds and 11 of. the nonpuffed sidestream group died “spontaneously”.The rats of the sham and the cage control groupsincreased their body weight during the 21 days ofexposureThe sidestream groups showed a decrease to approx. 80percent of their initial body weight.
  • 14. Tobacco Smoke & Cardiovascular Risk Non-linear Dose Response Pechacek TF & Babb S. BMJ 328:980-3, 2004.SOURCE: Pechacek & Babb, British Medical Journal, 2004. PubMed Central PMCID: PMC404492
  • 15. Brief SHS Exposure and Aortic Function • 16 male nonsmokers and 32 smokers (active or sham smoking) undergoing cardiac catheterization for chest pain • Aortic catheter to measure pressure and diameter • SHS exposure x 5 minutes vs. 1 cigarette vs. sham smoking •  aortic distensibility of 21%, 27% and 0%Stefanadis C. Ann Intern Med 128:426, 1998
  • 16. SHS and Coronary Circulation Acute Effects • Healthy smokers (n=15) and nonsmokers (n=15) • Coronary flow velocity reserve measures by transthoracic doppler echocardiography • Baseline and hyperemic (IV adenosine triphosphatae) phases • 30 minute SHS exposure in hospital smoking room • Abrupt reduction in coronary flow velocity reserve in nonsmokersOtsuka, R. JAMA 286:436-441, 2001
  • 17. SHS and Coronary Heart Disease • 4729 men age 40-59 followed for 20 years • Baseline tobacco use status and serum cotinine • Nonsmokers classified as light SHS exposure (0.7 ng/ml) or heavy SHS exposure (0.8-14.0 ng/ml) •  hazard ratios for heavy SHS exposure especially in first (3.73; CI 1.32-10.58) and second (1.95; CI 1.09-3.48) 5 year follow-up • Risk of CHD among heavy SHS exposure similar to light smokers (1-9 cpd)Whincup PH, et al. BMJ, doi:10.1136/bmj.38146.427188.55 (published 30 June 2004)
  • 18. Whincup PH, et al. BMJ, doi:10.1136/bmj.38146.427188.55 (published 30 June 2004)
  • 19. 1992 U.S. EPA Report• SHS is a Group A carcinogen (arsenic, asbestos, benzene, radon, vinyl chloride)• 3,000 lung cancer deaths/year in nonsmokers• 8,000 to 26,000 new asthma cases in children• 150,000 to 300,000 cases of bronchitis and pneumonia in toddlers• Smoke-free work place reduces SHS exposure
  • 20. Tobacco Smoke Constituents• Arsenic • Lead• Benzene • Nitrosamines• Benzo[a]pyrene • Phenol• Cadmium • Polycyclic aromatic hydrocarbons• Chromium VI • Vinyl chloride• Cresol Nov. 1, 2006 • Polonium 210 Nov. 22, 2006• Formaldehyde Alexander Litvinenko
  • 21. …probably the single most importantchallenge we currently face. This will have a very direct and major impact on consumption -- an impact which will be as bad as, or worse than, excise tax increases.
  • 22. We have been referring to our initial approachas “sand in the gears.” Our objective was toslow down the ETS risk assessment until wecould get broader policy declarations out of theAdministration. To be honest, we made everyeffort to prevent the Risk Assessment.
  • 23. Senator Helms further complained about SecretarySullivan’s statements… This position was furtherstrengthened by a Howard Baker to Sununu callindicating that Sununu was understanding of oursituation.
  • 24. Howard H. Baker, Jr.•Senator from Tennessee 1967-85•Chief of Staff in the ReaganWhite House 1987-88.•Former Chair of the Board of Trustees, Mayo Foundation.•Ambassador to Japan 2001-05• Baker, Donelson et al received$2.6M from cigarette companiesin 1998 alone.
  • 25. Science for Hire • Smoke-free indoor air policies  cigarette consumption • Global ETS consultant program intended to influence public opinion on secondhand smoke • Program run by U.S. lawyers because they “…have expertise in both scientific and public affairs arenas.” • Consultants wrote articles and books for scientific and lay press, presented at conferences, lobbied political figures, testified before legislative bodiesMuggli ME, et al. Nicotine Tob Res 5:303-314, 2003
  • 26. ETS Consultants Program1987 U.S.1988 Europe – France, Germany, Italy, Norway, Spain, Sweden, UK1989 Asia/Pacific – Australia, Hong Kong, Indonesia, Japan, Korea, Malaysia, Philippines, Singapore, Taiwan, Thailand1991 Latin America – Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, VenezuelaMuggli ME, et al. Nicotine Tob Res 5:303-314, 2003
  • 27. Hong KongDr John Bacon-Shone, Department of Statistics, University of Hong Kong, Biostatistics/environmental epidemiologyDr Linda Koo, Department of Community Medicine, University of HongKong, Scientist/ETS EpidemiologyDr Sarah Liao, EHS Consultants Ltd, Occupational healthDr Alun McIntyre†, Director, Consultants in Environmental Sciences (Asia)Environmental scienceDr Clive Ogle, Department of Pharmacy, University of Hong Kong, PharmacologyAssunta M, Fields N, Knight J, Chapman S. Tobacco Control. 2004;13(Suppl 2):ii4-12
  • 28. In a series of scientific articles, Dr. Koo has reported thatdiet, independent of exposure to ETS, appears to beassociated with the relatively high incidence of lung canceramong non-smoking Chinese women in Hong Kong.In particular, Dr. Koo reported that vegetables, meats andfish that are smoked, salted, cured or pickled areassociated with an increased lung cancer risk while freshversions of those foods are not.No significant association was reported in Dr. Koo’sinvestigations between ETS and lung cancer.
  • 29. Spring O‟Brien and the Euro Center Communications Grouphave been asked to put forward public relations proposals for animportant campaign in two categories of the country: Primary Countries France (in which research Germany is being conducted Italy and PR is required) Portugal Spain1.2 The “passive smoking” debate Sweden For the last 15 years since the anti-smoking lobby created the ETS issue, it has increasingly tried to focus on the „passive‟ smoker rather than the active smoker.
  • 30. 1.3 A new test method changes the debate In 1994, a respected research centre, Hazleton Europe, tested 225 people in Northern England. Subjects wore a This test demonstrated that the actual levels of ETS are personal sampler for 24 hours favourable reaction in the the This resulted in a surprisingly which precisely measured minimal. amount of exposure to tobacco smoke. media in many countries.
  • 31. 4.5.2 Objectives: Spain• Demonstrate the superiority of the more scientific methods used by the Hazleton study over epidemiology studies.• Create media interest in the Hazleton study not only for the findings but also for the method itself.
  • 32. 4. WINNING INFLUENCE• Build regular contact with priority opinion leaders in government, politics, media and the business community.5. RESOCIALIZATION OF SMOKING• The need to build good relations with key media contacts is of• To develop and exploit relevant BAT initiatives and core prime importance. materials on resocialization of smoking. We must promote the cause of sound science in terms of smoking issues and assure that fair regulatory regimes are established to provide for consumer freedom.
  • 33. The Latin Project • Financed by BAT (60%) and Philip Morris (40%) and administered by Covington & Burling • 1994 Total Budget $680,000: $210,000 for retainer agreements with “consultants” • 13 “consultants” from Argentina, Brazil, Chile, Costa Rica, Ecuador, Guatemala, and VenezuelaBarnoya J. Tob Control; 11:305-314, 2002
  • 34. Chilean Consultants to the Latin ProjectName Affiliation Activities Catholic University of Initial TrainingDr. Hector Croxatto Chile SessionDr. Lionel Gil Influence of outdoor University of Chile pollution on IAQ(toxicologist) Medical School paper publishedGuillermo Guesse Unknown Unknown(architect) Monitor governmentDr. Ricardo Katz Unknown activities on IAQ regulationsDr. Sergio Tezanos-Pinto University of Valparaiso Initial Training SessionBarnoya J. Tob Control; 11:305-314, 2002
  • 35. (C) Chile (i) Retainer relationships. Retainer agreements are proposed for Drs. Gil and Lopez……Dr. Gil would be expected to: (a) Respond promptly to media articles misrepresenting the science of ETS or calling for smoking restrictions for scientifically unjustified reasons.
  • 36. (b) Prepare and place twopopular articles discussingindoor air quality concerns.….to make scientificpresentations in opposition tosuch legislation. Budget: $20,000
  • 37. ETS Consultants Program Argentina• 1992 – Parliament passed strong legislation to restrict smoking in public places• Industry mounted massive public opinion campaign to encourage President Carlos Menem to veto the legislation• Dr. Carlos Alvarez – Personal Scientific and Technical Advisor to President Menem• Dr. Alvarez – Cardiologist, Professor of Medicine, and Head of Instituto de las Clinicas Cardiovasculares
  • 38. The reports we have received indicate that Dr. CarlosAlvarez played a very useful role in the largerindustry efforts to defeat, and then to convinceDr. Alvarez’s activities included conversations withPresident Menem to veto, the antitobacco legislationSenators by the Argentine and a series ofapprovedfrom both parties Parliament at the end ofconversations with President Menem as well as1992.President Menem’s brother, who serves as PresidentDr. Alvarez also provided President Menem with aof the Argentine Senate.briefing package and covering letter that pointed outthat the smoking restrictions that had been proposedlacked a solid scientific basis.
  • 39. …Dr. Alvarez expects to be paid for his efforts inconnection with the Argentine antismokinglegislation.…his assumption is that the industry expects tocompensate him for his efforts, which he believes tohave been of decisive importance.
  • 40. Smoke-Free Ordinances and Heart Attacks • Helena, MT: Monthly admissions for AMI ↓ 40 → 16 (CI -31.7 to -0.3) Sargent, RP. BMJ 328:977, 2004. • Pueblo & El Paso, CO: ↓ Admissions for AMI in Pueblo 257/100,000 person years → 187 vs. El Paso 119 → 116. (Post to Pre RR 0.73 vs. 0.97) Bartecchi, C. Circualtion. 114:1490, 2006. • Scotland : 19% ↓ Admissions for troponin confirmed Acute Coronary Syndrome Pell JP, et al NEJM 359:482, 2008 • Bowling Green & Kent, OH: 47% ↓ Admissions for CHD 3 years after ordinance • Khuder ,SA. Prev Med 45:3,2007
  • 41. AMI Counts Per 100,000 Person Years Bartecchi, C. Circualtion. 114:1490, 2006.
  • 42. Smoke-free Laws and Cardiovascular Events in Olmsted County MN To evaluate the population impact of smoke-free laws on the incidence of Myocardial Infarction (MI) and Sudden Cardiac Death (SCD) in Olmsted County during the 18-month calendar period before and after implementation of each smoke-free ordinanceHurt RD et al Arch Int Med 172:1635, 2012Funded by Clearway Minnesota and NIH (R01 HL59205, R01 AG034676) ©2011 MFMER | 3152300-45
  • 43. The Rochester Epidemiology Project (REP)• Medical records linkage system• Links and archives medical records of virtually all persons residing in Olmsted County, Minnesota• Identifies patients through their outpatient (office, urgent care, or emergency department) and hospital contacts across all local medical providers ©2011 MFMER | 3152300-46
  • 44. Incidence Rates and Relative Risks ofMI and SCD 18 Months Pre- and Post- Smoke-free LawsMI Incidence Rate comparisons Age & Sex-Adjusted Rate per 100,000 (95% CI) Adjusted HR (95% CI), P Prior PostPre-Ordinance # 1 vsPost-Ordinance #2 n = 187 150.8 (129.0-172.6) n = 139 100.7 (83.8-117.5) 0.67 (0.53-0.83), <0.01SCD Incidence Rate comparisons Age & Sex-Adjusted Rate per 100,000 (95% CI) Adjusted HR (95% CI), P Prior PostPre-Ordinance # 1 vsPost-Ordinance #2 n = 143 109.1 (91.0-127.2) n = 133 92.0 (75.7-108.3) 0.83 (0.65-1.06), 0.13*Adjusted for age and sex
  • 45. Prevalence of Self-Reported High Cholesterol, Diabetes, Hypertension and Obesity in Minnesota, 1999-2010 fromthe Behavioral Risk Factors Surveillance System (BRFSS) 40 High Cholesterol 25 HypertensionPrevalence (%) Prevalence (%) 30 20 15 20 10 10 5 0 0 2000 2008 1999 2001 2002 2003 2004 2005 2006 2007 2009 2010 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 8 Diabetes 30 Obesity (BMI 30 kg/m2)Prevalence (%) Prevalence (%) 6 20 4 10 2 0 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2000 2004 1999 2001 2002 2003 2005 2006 2007 2008 2009 2010
  • 46. Prevalence of Self-Reported Current Smoking in Minnesota, 1999-2010 from Behavioral Risk Factors Surveillance System (BRFSS) Current Smokers 25Prevalence (%) 20 15 10 5 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Year
  • 47. Conclusions• The implementation of smoke-free ordinances was associated with 33% decrease (p< 0.01) in MI and 17% decrease (p= 0.13) in SCD• The magnitude is not explained by secular trends, community concurrent interventions or changes in known cardiovascular risk factors• SHS exposure should be considered a modifiable risk factor for MI and SCD• All people should avoid SHS exposure but people with known CV disease should have NO exposure to SHS
  • 48. Smoke-free Laws and Reduced AMI How Could This Be True ? • Non-linear dose response to SHS • People with pre-existing CAD • SHS → ↑platelet adhesiveness • SHS →  Endothelial dysfunction →  arterial dilatation • SHS →  Coronary velocity reserveJuster HR, et al, Am J Public Health 97:2035, 2007
  • 49. We do know that choice and accommodationwith regard to smoking are two powerful andpositive positions. And, our spokesmen cannotutter those two words enough.
  • 50. Smoke-Free Ordinances Restaurant and Bar Revenues • Sales tax data • 15 cities with smoke-free restaurants • 5 cities and 2 counties with smoke-free bars • Matched comparison cities and counties with no restrictions • No significant difference in total retail sales in eating and drinking places or on ratio between sales in comparison communities • Smoke-free bar ordinances had no significant effect on fraction of revenues going to eating and drinking places that serve liquorGlantz SA. Am J Pub Health 87:1687-1693, 1997
  • 51. Also, the economic arguments often used bythe industry to scare off smoking ban activitywere no longer working, if indeed they ever did.These arguments simply had no credibility withthe public, which isn’t surprising when youconsider that our dire predictions in the pastrarely came true.
  • 52. U.S. Surgeon General Report 2006 6 Key Findings• Detectable cotinine concentrations in 88% of non-smokers (1988) → 43% (2002)• Secondhand smoke causes disease and premature death in children and adults• ↑ risk of SIDS, acute respiratory infections, ear infections and more severe asthma in exposed childrenwww.surgeongeneral.gov/library/secondhandsmoke
  • 53. U.S. Surgeon General Report 2006 6 Key Findings (cont.)• Immediate adverse effects on C.V. system in exposed adults and causes heart disease and lung cancer• No risk-free level of exposure• Eliminating smoking indoors protects non-smokers but ventilation and/or separation do not.www.surgeongeneral.gov/library/secondhandsmoke
  • 54. 2006 U.S. Surgeon General Report Cigarette Company ResponsePhilip Morris- “We are studying the report.”R.J. Reynolds- “…..does not change our views about secondhand smoke.” “There are still legitimate scientific questions concerning the reported risks of secondhand smoke.” “People who don’t want to work around it don’t have to work at that establishment”
  • 55. “Public promises were intended to deceive the American public into believing that there was no risk associated with passive smoking and that Defendants would fund objective research to find definitive answers. Instead, over the decades that followed, Defendants tookRacketeers steps to undermine independent research, to fund research designed and controlled to generate industry favorable results, and to suppress adverse research results” United States et.al. v. Philip Morris et. al. (2006) Honorable Gladys Kessler, United States District Court for the District
  • 56. December 2007 September 2009We owe it to our grandchildren
  • 57. No matter how innocent they appear,the tobacco industry CANNOT BE TRUSTED!
  • 58. 63 Y/O Male Physician• Stopped smoking over 30 years ago(1975).• Strong family history of CAD.• Asymptomatic.• Regular exercise echo because of family history.• Positive exercise test led to coronary angiogram.
  • 59. 63 Y/O Male Physician How do you advise the patient about eating in a restaurant or bar where smoking is allowed?A. It isn’t a big deal. Not to worry.B. If you start having chest pain take an aspirin.C. Best to completely avoid secondhand smoke exposure.D. Eat at home or at MacDonald’s where it is smoke-free.
  • 60. 63 Y/O Male Physician• There was significant 3 vessel disease- RCA, circumflex, and 1st diagonal.• CABG vs angioplasty and stents.• Successful angioplasty and 7 drug eluting stents placed.• Dismissed on Plavix, ASA, Celebrex, simvastatin.• Total cost $85,000.
  • 61. 63 Y/O Male Physician Now what do you tell the patient about eating in a restaurant or bar where smoking is allowed?A. You are fixed. Not to worry.B. Make sure you do not forget to take your Plavix and ASA. Wouldn’t want your platelets to aggregate.C. Eat at MacDonald’s. It is smoke-free and not to worry about Big Mac’s or french fries. You are fixed.D. Urge your city council to make all work places smoke-free