Involuntary smokers face health risks

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AMERICANS smoked 595 billion cigarettes last year. This comes to 3384 cigarettes per adult–fuel for plenty of damage. However, this is the lowest consumption figure since 1944, when the per capita figure hit 3039, still moving up toward its peak in 1963 of 4345.

This suggests that there has been some progress in educating the public since the famous surgeon general’s warning on tobacco in 1964. Despite the tobacco industry’s high-priced efforts to obscure it, the message may be getting through that smokers are far more likely than nonsmokers to get cancer or die prematurely.

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On 14 November the National ResearchCouncil, the study branch of the National Academy of Sciences, released a new indictment of smoking that describes the injury done by tobacco smoke to nonsmokers. The report, Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects, was written on contract for the Environmental Protection Agency and the Department of Health and Human Services, which may decide to regulate tobacco smoke as an air pollutant.

The report’s main findings are that (i)young children are more likely to have respiratory problems and require medical attention if they are raised by smoking than nonsmoking parents, (ii) adults who have never smoked are significantly more likely to get lung cancer if married to smokers than if they are not, and (iii) many people suffer severe eye and nose irritation when exposed to tobacco smoke, an effect that can be relieved by a five fold increase in ventilation.

Barbara Hulka, chairman of the study group and of the epidemiology department at the University of North Carolina’s School of Public Health, presented these findings on 14 November to a packed news conference. She spoke just after pro- and anti tobacco lobbyists had clashed in ritualistic fashion on the Academy’s steps.

A tobacco industry spokesman had summoned reporters to let them know that he viewed this new report as a retreat from earlier warnings about tobacco. (His view was contradicted in the official press conference.) Then activist John Banzhaf, director of Action on Smoking and Health (ASH) intervened with his own vocal critique of the tobacco industry. When it was over, reporters filed inside, where camera gear lined the back of the lecture hall and technicians lolled impatiently. A group of them fell into a mock coughing fit when ont lit a cigarette. An Academy staffer asked the smoker to put it out, which he did, saying in bewilderment, “They’re serious.”

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The occasion was indeed serious, despite the antics, for it highlighted once again the frustrating set of problems posed by tobacco use. Hulka told the audience several times that the scientists had not been asked to make policy recommendations and did not intend to. Nevertheless, she said that the evidence on the damage to children’s health was so strong that the group felt it had to speak up on this point. The report says: “Since children exposed to environmental tobacco smoke (ETS) from parental smoking have an increased frequency of pulmonary symptoms and respiratory infections, it is prudent to eliminate ETS exposure from the environments of small children.”

On the basis of a review of epidemiological studies, the panel found that children of smokers had a 20% to 80% greater risk of respiratory problems than other children. It is not clear whether the smoke itself or proximity to a disease-prone parent causes these problems, but the report did find the illnesses more strongly associated with smoking by the mother than by the father. The panel also endorsed an earlier finding that smoking by the mother during pregnancy is associated with a low birth weight of the child. Finally, there is “some evidence” that exposure to tobacco smoke slows the rate at which a child’s lungs grow.

The NAS panel treated the subject of lung cancer with caution. The study notes that lifelong nonsmokers married to smokers have a significantly greater risk of getting lung cancer than those with a nonsmoking spouse (about 30% greater). But it did not attempt to calculate the number of excess cancers induced by “passive smoking.” For perspective, Hulka pointed out that the risk of getting cancer is 1000 times as great for the active smoker than for the nonsmoker.

An appendix by James Robins, an epidemiologistat the Harvard School of Public Health, did attempt to calculate the number of excess cancers. His work was not endorsed by the panel becuase it arrived late and was loaded with “potent math,” as one observer said, apparently too potent to be deciphered in time for the press conference. But it was published. Robins estimated that of the 12,000 lung cancer deaths in 1985 among nonsmokers, over 2400 were caused by environmental tobacco smoke.

Robins’ estimate fits with that of a British researcher, Nicholas Wald, who has published several papers recently on passive smoking and lung cancer. Wald, a member of the NAS panel, developed an effective way of detecting exposure to environmental tobacco smoke by measuring cotinine, a metabolite of nicotine, in the blood. This measure works well because there is no confusing the cotinine level of an active smoker with that of an involuntary smoker, the former being 100 times as great as the latter. Furthermore, people who do not work or live with smokers have a cotinine level of zero. The three exposure levels are thus easily distinguished by an objective measure.smoke deter

Using the cotinine marker, Wald has nowvalidated a number of epidemiological studies on smoker-nonsmoker couples. He also reviewed the risk results of 13 studies and concluded that, after bias is removed, there is clear evidence that nonsmokers who live with smokers face a 35% higher risk of getting lung cancer than those who do not live with smokers. He estimates that in the United Kingdom around 300 nonsmokers die each year of lung cancer induced by tobacco smoke. He thinks Robins’ estimates for the United States are compatible with his own.

This is one of many areas in which theAcademy panel saw a need for further research. Chief among the items on the agenda is the need for research on exposure to tobacco smoke in the workplace and on ways to reduce it.

Little is known about diseases other thanlung cancer that may be stimulated by ambient tobacco smoke, although experience with active smokers suggests that there is reason for concern. This is another “important topic for future epidemiologic inquiries,” according to the report.

Many issues remain unresolved, but one clear implication of this study is that smoking presents a public health threat broader than generally appreciated. It endangers not just the health of those who are competent to accept such risks, but also children, who are not.