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Passive Smoking: A summary of the evidence

The California EPA identified passive smoking as a risk factor for the following:

Childbirth and infancy

Low birthweight

Cot death (SIDS)

Illnesses in children

Middle ear infection

Asthma (induction & exacerbation)

Bronchitis (induction & exacerbation)

Pneumonia (induction & exacerbation)

Illnesses in adults

Heart disease

Stroke

Lung cancer

Nasal cancer

The California EPA report also identified a link between passive smoking and the following:

Spontaneous abortion (miscarriage)

Adverse impact on learning and behavioural development in children

Meningococcal infections in children

Cancers and leukaemia in children

Asthma exacerbation in adults

Exacerbation of cystic fibrosis

Decreased lung function

Cervical cancer

The UK population is about 56 million, so if there were the same per capita impact as the United States, this study would suggest around 8,000 dying of heart disease caused by passive smoking each year in the UK.

Since then, studies have shown conclusively that not only does exposure to ETS increase the risk of heart disease in non-smokers but that the risks are non-linear. It would appear that even a small exposure to tobacco has a large effect on heart disease, with further exposure having a relatively small additional effect. This may be explained by the fact that exposure to ETS causes the blood to thicken – a phenomenon known as platelet aggregation. New research has shown that even half an hour’s exposure to environmental tobacco smoke by non-smokers is enough to adversely affect cells lining the coronary arteries. The dysfunction of these endothelial cells contributes towards the narrowing of arteries and a reduction in blood flow. [16]

Unlike the risk for lung cancer, where the risk is roughly in proportion to smoke exposure, passive smokers’ risk of heart disease may be as much as half that of someone smoking 20 cigarettes a day even though they only inhale about 1% of the smoke.

PASSIVE SMOKING

Passive smoking is a cause of additional episodes and increased severity of symptoms in asthmatic children. Asthmatic children are up to 2.5 times more likely to have their condition worsened by passive smoking. In the United States alone it is estimated that 200 000 to one million asthmatic children have their condition worsened by passive smoking.

Exposure to environmental tobacco smoke (ETS or “passive smoking”) is a risk factor for new cases of asthma in children who have not previously displayed symptoms.

The risk of lower respiratory tract diseases (such as croup, bronchitis and pneumonia) is estimated to be about 50-60% higher in children exposed to ETS during the first 1-2 years of life, compared with unexposed children. About 10-15% of lower respiratory tract disease in young children under 18 months of age is attributable to passive smoking.

In children, exposure to environmental tobacco smoke is causally associated with increased prevalence of fluid in the middle ear, symptoms of upper respiratory tract irritation, and a small but significant reduction in lung function.

Environmental tobacco smoke is a cause of lung cancer in lifelong non-smokers exposed to ETS. Epidemiological studies carried out in several countries suggest that the lung cancer risk is about 20-30% higher than for never smokers not exposed to ETS.

The truth is that one out of every two long-term smokers will ultimately be killed by tobacco. In developed countries, half will be killed in old age, after age seventy, but the other half will be killed in middle age, before age seventy, and those who die from smoking before age seventy will lose more than 20 years of life expectancy.

The truth is that four million people die yearly from tobacco-related diseases, one death every eight seconds. If current trends continue, WHO estimates that the toll will rise to ten million by 2030, one death every three seconds. Tobacco is fast becoming a greater cause of death and disability than any single disease.

It doesn’t have to be that way. WHO has decided to focus attention and resources on tobacco use, to try to prevent at least some of these predicted deaths, and to prevent hundreds of millions to more in the decades to come after 2030.

How many deaths?

Tobacco is a silent killer. Peaks in tobacco mortality reflect peaks in tobacco consumption three to four decades earlier. Current smoking mortality is the result of past lifetimes of tobacco consumption.

From 1950 to 2000, tobacco will have killed more than 60 million people in developed countries alone, more than died in World War II.

If current trends continue, tobacco will kill more than 100 million people in the first two decades of the 21st century.

If current trends continue, 500 million people alive today will be killed by tobacco.

Of the 300 million Chinese men now aged 0-29, at least 100 million will eventually be killed by tobacco. Half the deaths will be among those aged 35-69.

In the Former Socialist Economies (FSE), around 14% of all deaths were traced to tobacco use in 1990. By 2020, this figure is slated to rise to 22%. And smoking is the major risk factor responsible for a predicted 56% increase in male deaths from chronic diseases in FSE countries from 1990 to 2020.

How much illness?

Tobacco is a known or probable cause of some 25 different diseases. For some, like lung cancer, bronchitis and emphysema, it is the major cause.

Other people’s tobacco smoke contains essentially all of the same carcinogens and toxic agents that are inhaled by the smoker. Other people’s tobacco smoke is harmful to non-smokers because it causes lung cancer and other diseases, and aggravates allergies and asthma.

Tobacco consumption has been explicitly linked to high incidence and gravity of cardiac disease.

Maternal smoking is associated with a higher risk of miscarriage, lower birthweight of babies and inhibited child development. Parental smoking is also a factor in sudden infant death syndrome and is associated with higher rates of respiratory illnesses, including bronchitis, colds and pneumonia in children.

How many smokers?

WHO estimated that there were 1.1 billion smokers in the world at the beginning of the 1990s, 300 million in developed countries and 800 million in developing countries. About one-third of the world’s adults were smokers at the beginning of this decade, and there is little sign that this proportion has changed substantially since.

At the beginning of the 1990s, 47% of men and 12% of women were smokers. In developing countries, it was estimated that 48% of men and 7% of women were smokers, while in developed countries, 42% of men and 24% of women were smokers.

Tobacco use among adolescents remains stubbornly persistent. Smoking prevalence among adolescents rose in the 1990s in several developed countries . While new markets are being opened by tobacco industry actions, old markets have not been closed – tobacco is a global threat.

Tobacco and smoke concern us all, smokers and non-smokers alike. Tobacco is everybody’s problem. It is a major public health issue that demands urgent action now.

Honest science or propaganda?

Bernie Greene wonders just how scientific is the science behind the smoking debate over on Samizdata.

I shall have to assemble a category on smoking – I like the last comment the best. He pretty much blows Bernie out of the water – and at least Bernie did ask for a more educated opinion.

As an epidemiologist, I hardly know where to begin with this post. I encourage the author to read an introductory book on epidemiology before dismissing the field; I suggest Epidemiology in Medicine by Charles Hennekens. If he did read it he might not be a skeptic about smoking and lung cancer. To wit- there are several criteria that denote causality. Among them are temporality (exposure preceded disease), dose-response (more exposure = more disease), strength of effect (bigger numbers means that biases are less likely to have produced them) and biological plausibility (lung exposed to floating carcinogens… hmmmmm). Smoking fulfills all of these criteria.

The author also appears not to know that causes come in different types. They may be necessary but not sufficient to cause disease. In this type of causation it is not surprising that only a fraction of exposed people develop disease.

To read the author you would think that all research on lung cancer stopped in the 50’s, when in fact plenty of research continues to this day that explains, among other things, genetic susceptibility to developing lung cancer among smokers. For instance, N-acetyltransferase is an enzyme that clears tobacco carcinogens from the body. People with the slow-acting form (slow acetylators) are at a higher risk for lung cancer than people with the fast-acting form (fast acetylators). So it’s not as if there is no curiosity on the part of scientists to find out what else, besides smoking, affects risk of lung cancer. There’s an enormous literature on the subject if anyone cares to look on Medline. Incidentally, I would like to imagine the author coming up with a concise way to tell the public that it’s alright to smoke if they have the correct genetic polymorphisms for thirty different susceptibility genes.

Lastly, the author criticised unnamed scientists for demanding something be done about tobacco. I truly doubt the author did anything like go back to the historical record to determine who advocated what law and when. Nevertheless, I’d agree that most of my fellow scientists instinctively fall back on statist solutions to modify disease risk. But let’s be clear- that does not invalidate the science. I’m sure the author can recognize an ad hominem argument when he sees one.

Finally, here is a brief list of eliminable exposures and the diseases they caused as described by the dread Epidemiology:

sleeping baby on the stomach – SIDS Hepatitis C – hepatocellular carcinoma diesterstilberol – vaginal cancer Rely tampons – toxic shock syndrome L-tryptophan – eosinophilia myalgia sydrome HIV – AIDS

On behalf of my field, I accept your thanks.

Logan Spector

The Smoking thing again

Right, I’ve just read the consternation that Stephen Pollard caused by his backing and then subsequent backing down over supporting a smoking ban.

This was in part thanks to a tirade on the part of Harry Hatchett.

I also created quite a stir on my own blog, and there was quite a reaction to my comments over on Samizdata.

The thing is, I have so many arguments coming at me its hard to deal with each one. But I will try and cover the overall thrust of the arguments. I will try and list the objections as I see them…

1. The market should decide.
2. The State has no right to interfere with what goes on on private property.
3. I am a vested interest.
4. The ban is unenforceable.
5. The loss in tax revenue would be substantial.
6. Smoking is a social interaction.
7. Jobs in the tobacco industry would be lost as a result.

Gosh. Where to start.

Firstly, Frank McGahon. He noted:

I maintain that smoke-free workplaces are a good idea. My own workplace is non-smoking. I just don’t think a crude government ban, and one which treats all workplaces as identical, is an appropriate approach.

And…

“This will cost the economy” or an argument about health risks of “second hand smoke”. Most frustrating of all is the notion that a “correct balance” be achieved between the “rights” of smokers and non-smokers. There is no argument from principle. Non-smokers are all for it and smokers (and publicans) are mostly against it. It seems to be taken for granted that it is appropriate for governments to take crude measures such as these, and the argument is just about the finer points of implementation.

And…

Try to be “critical” of your own position on this. Remember you are a “vested interest”. If you work in a smoky premises and you have the opportunity to receive the benefit of a non-smoky workplace “free” (i.e. no loss in salary, convenience, etc) of course you will welcome it. It is a rational selfish choice but that doesn’t mean it is a principled position.

I am a non-smoker, I hate smoky restaurants and I’m not too keen on smoky pubs. I will receive a benefit “free” if the smoking ban is successful but it is still wrong. The fact is, people smoke in pubs because publicans recognise that smoking on premises attracts more smoking punters than deters non-smokers. If more people actually wanted non-smoking premises a properly functioning market would provide them (and you see this in restaurants).

Try to imagine the smoking ban from a different angle: take some hobby of yours and imagine that a government restriction was placed on it, not a ban (that would be “heavy-handed”!) but enough to be an inconvenience. Would you feel frustrated or would you accept that the government had a right to regulate and restrict your behaviour?

Yes, Frank, smoke-free workplaces are a great idea. But why the qualification? Why is one persons workplace better than another? If a government imposed ban is not the solution, then what is? God knows the Vintners rant on about ‘air-changes per hour’, but to anyone who’s worked in bars you know that the effect of that is negligible.

Secondly, there is an argument from principle. I believe that people have a right to work in a healthy environment – most especially where an unhealthy working environment can be changed instantly into a healthy one – as in the case of bars. It is incorrect to say that smokers are all for it, indeed in the polls I read, many smokers were in favour of the ban.

Thirdly, damn right I’m a vested interest, as is my health, and the health of all bar workers. I’m not sure of the validity of the position that “publicans recognise that smoking on premises attracts more smoking punters than deters non-smokers”. Publicans don’t care whether people smoke or not; they want them to buy beer.

It just so happens to some of the public are addicted to a substance that pollutes the environment around them, badly affecting the health of their colleagues and the staff on a premises. The question is whether a persons right to smoke precedes other people’s right to health, and whether that position is voluntary or involuntary.

Fourth, you compare smoking to a hobby. It’s not, it’s a dangerous addiction. People playing tennis is a hobby, and hey I dont mind people playing tennis – people playing cards in a pub is a hobby, and fine, there’s no cards affecting my health.

In my view, the government, just like in other employment legislation, has a right to give rights to workers. I have a right to x days holidays, I have a right to a healthy working environment.

Harry Hatchett next:

I could link to some piece of sponsored American ‘scientific research’ maybe called “Debunking the Myths of Passive Smoking” showing that fags don’t really do much harm after all. I could recall the failures of prohibition. I could point out that thousands of workers for tabacco companies will lose their jobs (especially in the developing world that anti-globalisation activists pretend to ‘care’ about). I could compare the ‘damage’ from cigarette smoke with the impact of car fumes (I suppose you want to stop my right to drive a car as well Stephen?).

Then I could raise the frightening question of how Stephen’s ‘Orwellian’ lung police are going to enforce such a ban across the length and breadth of our once-free country?

Passive smoking has a serious affect on health, many studies point to it.

Only 30 minutes of exposure to [passive smoke] causes platelets in the bloodstream to become stickier. When that happens, blood clots form more easily, which can block arteries and cause heart attacks.

Dr. Richard Sargent, one of the study’s authors, points out that eight hours of working in a smoky bar is equivalent to smoking a pack of cigarettes a day. In such an environment, other studies have shown, workers more than double their chances of developing cancer and asthma, and pregnant workers put themselves at risk for miscarriage and premature delivery.

A poll released this month by Quinnipiac University in Hamden, Connecticut, reported that 59 percent of voters in the [New York] state favor prohibiting smoking in public places. Another survey, commissioned in August by anti-smoking groups, found that 70 percent of New York City voters support it.Smoking in public places also sets off an enormous domino effect in public-health spending by creating or worsening illnesses whose treatment costs are eventually shouldered by taxpayers.

Comparing alcohol prohibition to banning smoking in public places is incorrect. The argument is not to ban smoking outright – it is to ban smoking in places where people must involuntarily inhale pollutants, in a venue where such a situation can be avoided.

As for thousands of jobs of people that grow tobacco – that is also another argument that does not follow. Whether or not smoking is banned in public places, does not necessarily mean people will stop smoking, it might only encourage people to stop. And the subtext of your argument is that people should continue to smoke in order to support employment in third world countries where people are paid pittance by companies to grow a crop that kills the customers of those companies.

Pollution from cars occurs in an open environment that cannot be controlled, unless you ban cars. Smoking in pubs is a closed environment that can be controlled by banning smoking therein, but people can smoke outside where it does not affect the health of those around them.

The policing issue I think is interesting. I could bring up smoking on aircraft, and compare that to smoking in bars. Why no fight for the right for people to smoke on aircraft, or is airline policy/government legislation about smoking on flights also too much of an infringement on civil liberties?

I think people will just get used to it – policing would not be hugely expensive as it would be down to the proprietor to ensure that people are not smoking, as will be the situation in Ireland, and I believe it is in NY.

Interesting from the IHT article is the fact that in Helena, Montana –

For city residents, the rates [of heart attacks] plummeted by 58 percent in only six months.

‘‘We know from longer-term studies that the effects of secondhand smoke occur within minutes, and that long-term exposure to secondhand smoke is associated with a 30 percent increased risk in heart-attack rates,’’ says Stanton Glantz, a professor of medicine who conducted the study’s statistical analysis. ‘‘But it was quite stunning to document this large an effect so quickly.’’

Quite. A 58% drop in heart attacks. Think of the money saved by the NHS. In fact, think of the people who would live, rather than die. Furthermore let me lighten the argument with an excellent quote from Bill Hicks (who died of cancer)

Whooh! It’s weird not smoking, I’ll tell you that. But I’m glad I quit y’know because I felt like to be honest with you I was on the wrong side of the war against drugs, because I smoked cigarettes and gave the tobacco lobbyists and the tobacco growers any more fuckin money for the poison they spread, and advertise all over our world thanks to: marketing! Hey [coughs] looks like that’s 15 Luv. You know what I mean isn’t that wild? y’know? The war on drugs to me is absolutely phoney, its so obviously phoney, ok? It’s a war against our civil rights, that’s all it is. They’re using it to make us afraid to go out at night, afraid of each other, so that we lock ourselves in our homes and they get suspending our rights one by one. And the fight against the war against drugs . And we’re so afraid “It all makes sense to us, it’s good they’re doing a good job” Because if the cared about us they’d get rid of the number one killer: cigarettes. Kills more people than all of the drugs times one hundred….legally. Marijuana, a drug that kills… no one…. and let’s put in a timeframe… ever. Marijuana is against the law. Now you think Pot with those kinda statistics could walk into any debate on the legalisation of drugs with confidence don’t you? “I am Pot I am going to meet nicotine and alcohol for a debate about legality hahaha” “Wait ’til they see my stats” “Frame up!” Why is pot against the law? It wouldn’t be because anyone can grow it and therefore you can’t make a profit off it would it? hahaha I’m spit balling but yeah ok yeah [clapping] alright yeah “Too fucking obvious Bill”.

One other notable critic was Verity over on Samizdata, who noted:

Dear Gavin, or may I address you as Mr Intolerance? If you “choose” to work down a coalmine, you will have to accept that you will be working underground and breathing in coal dust. If you “choose” to work as a ship’s steward, you will have to accept that you will be spending most of your life on the high seas and be vulnerable to sea sickness. People who “choose” to work in a bar accept that they will be working in smoky surroundings. The world is not going to bend to your personal will and attend to your comfort. Cruise liners aren’t going to turn themselves into non-floating hotels in permanent drydock lest you suffer from seasickness and the breadth of your career choice be thus diminished.

By the way, is it OK for people who visit bars to drink, or does the second hand smell of whisky breath nauseate you? We can always ban it and only serve non-alcoholic beverages if that would suit you better.

You don’t want to work underground, on the high seas or in a smoky environment? Avoid those careers. By the way, the myth of passive smoking is just that: a myth concocted by the antismoking industry. My goodness, Gavin, lighten up! Or, in your own tolerant words, get over it.

1. A coalmine is not a bar – and little can be done to avoid to pollutants in the air. Unlike in bars, where smoking can be banned, or at least sectioned off.

2. A ship is not a bar, and sea sickness does not kill you (at least as far as I am aware). Please compare like with like.

3. People who choose to work in bars should not have to choose to work in a unhealthy environment. This is the point. I should be able to work in a job that is healthy.

4. They can drink as much as they want, and while the smell of whiskey breath does nauseate, it does not cause the platelets in my blood to become sticky after thirty minutes, or increase the likelihood of my developing cancer by 30%.

5. Passive smoking is not a myth.

6. I take it that ‘lighten up’ was a pun?

7. ‘Get over it’ was only added to add fuel to the fire. And it was successful.

Ban on smoking in public places

I recently met Perry in London where we briefly discussed the ins and outs of banning smoking. He was all against it, and I, for my sins, did not see a problem with it. Maybe its down to personal experience.

Most of the comments left over on Samizdata support Perry in his argument – include my old mate Frank McGahon.

So l am going to attempt some form of rebuttal.

1. Smoking kills.
2. Passive smoking kills.
3. People smoke.
4. People smoke in public places – hence they are called ‘public’.
5. People have rights.

I can choose to work in a bar, or I can choose not to. But in choosing a profession or job should I also have to make a choice about my health? Why should I have to choose whether or not I work in a healthy environment?

Surely everyone has a *right* to work in a healthy environment? If you work in an office and a no-smoking policy has been implemented by your employer, is that an attack on your civil rights, or an attempt to either stop litigation, or save the health of employees?

Equally if people work in public places, and believe it or not people do, do they not also have the right not to be exposed to a smoke environment?

I should not have to decide that I can either a) work in a healthy environment, or b) work in an unhealthy one. All working environments should be healthy. If it was a matter of choice not many people would work in bars – but they do, and smoke is an extremely unhealthy side effect.

Perry argues that: I do not smoke, though I did puff on a Havana recently, and I generally do not like smoke filled rooms. However, I do not have anyone holding a gun to my head forcing me to go into a smoke filled room against my will or compelling me to take employment with someone who allows people to smoke on their private property (such as a restaurant or bar owner). And yet millions of people see nothing wrong with legitimising threats of violence against others to force them to not smoke for nothing more than their personal convenience.

Perry, saying that inhaling second hand smoke is a matter of personal inconvenience, rather than a direct effect on my health is to miss the point.

I don’t think the State is being heavy handed in Ireland. If people want to smoke, fine, but do it where it only affects the health of the person who chooses to smoke, and their fellow smokers. If you want to smoke around people who are working in public places then tough. Get over it.

Secondhand smoke kills

Rosemary Ellis from the NYT, talks about the town of Helena, Montana, where dramatic effects were seen on health when smoking was banned in public places and then reintroduced.

First a note on Rudolphs recent visit to Ireland – who are about to ban smoking in all public places, and also have the highest incidence of heart disease in Europe.

Six months into New York City’s smoke-free ordinance, there has been a spate of criticism about the wisdom of sticking by such a ban. The most notable came in a roundabout swipe from none other than former Mayor Rudolph Giuliani, who declared during a trip to Ireland last month that Irish citizens should have the choice to smoke in public places. (Giuliani later tried to distance himself from his comments.)

Then this staggering figure:

The study showed two trends. First, there was no change in heart attack rates for patients who lived outside city limits. But for city residents, the rates plummeted by 58 percent in only six months.

‘‘We know from longer-term studies that the effects of secondhand smoke occur within minutes, and that long-term exposure to secondhand smoke is associated with a 30 percent increased risk in heart-attack rates,’’ says Stanton Glantz, a professor of medicine who conducted the study’s statistical analysis. ‘‘But it was quite stunning to document this large an effect so quickly.’’

And like Ireland, pressure was put on by the Vintners:

It was also stunning to witness what happened next. The Montana state legislature, under pressure from the Montana Tavern Association and tobacco lobbyists, rescinded the ban in December. As a result, heart-attack rates bounced back up almost as quickly as they dropped.

And I work in bars too, by the way…

The bottom line of Helena’s plummeting then soaring heart attack rate is painfully obvious: Secondhand smoke kills. Only 30 minutes of exposure to it causes platelets in the bloodstream to become stickier. When that happens, blood clots form more easily, which can block arteries and cause heart attacks.

Dr. Richard Sargent, one of the study’s authors, points out that eight hours of working in a smoky bar is equivalent to smoking a pack of cigarettes a day. In such an environment, other studies have shown, workers more than double their chances of developing cancer and asthma, and pregnant workers put themselves at risk for miscarriage and premature delivery.

All of which make Giuliani’s comments particularly ill informed. And although the tobacco lobby continues to finance a campaign claiming that New Yorkers are unhappy with the ban, a poll released this month by Quinnipiac University in Hamden, Connecticut, reported that 59 percent of voters in the state favor prohibiting smoking in public places. Another survey, commissioned in August by anti-smoking groups, found that 70 percent of New York City voters support it.Smoking in public places also sets off an enormous domino effect in public-health spending by creating or worsening illnesses whose treatment costs are eventually shouldered by taxpayers.

For all of these reasons, New Yorkers can’t afford to be as easily defeated as the citizens of Helena – nor as easily manipulated by the tobacco lobby and the politicians who are in its pocket.

Ban smoking in public places, everywhere.

Horny sex alcopops

Karlin has also linked to a story in today’s Observer on new drinks to appear on the market this month. They are your average alcopops, like Bacardi Breezer or Smirnoff Ice – but with a twist.

Powerful blends of Chinese aphrodisiacs, vodka and passion fruit will create a ‘generation of randy super beings’, according to drinks manufacturers who expect the new tipples to rock the market the way alcopops did in the 1990s.


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