Experts Targeting Smoking and Secondhand Smoke Worldwide

From Heartwire

Michael O'Riordan

June 21, 2010 (Beijing, China) — Smoking, particularly the effects of secondhand smoke in nonsmokers, took center stage at the World Congress of Cardiology (WCC) 2010 last week, with experts calling on cardiologists to play a pivotal role in getting their patients to quit smoking and to reduce smoking in their communities.

"As a cardiologist who actively sees patients, one of the most important things I can do is tell them to stop smoking," Dr Sidney Smith (University of North Carolina, Chapel Hill) told the media during the WCC meeting last week. "It is arguably the major risk factor in the world right now, and if you wanted to do something to really make things better on this planet, you'd get rid of smoking and tobacco use."

Smith, the president-elect and chair of the World Heart Federation scientific advisory board, said the new National Institutes of Health (NIH) cardiovascular risk-reduction guidelines, of which he is a chair, will stress the importance of smoking cessation. "I want to be very clear where I stand on the importance of smoking cessation and tobacco use and the danger not only to the person who is smoking; [there is] also a very important risk in secondhand smoke."

If you wanted to do something to really make things better on this planet, you'd get rid of smoking and tobacco use.
An estimated 20% of cardiovascular disease worldwide is caused by tobacco, and yet, surprisingly, not everybody is aware of the link between cardiovascular disease, smoking, and secondhand smoke. In China, for example, just 4% of smokers are aware that smoking causes heart disease, said Smith.

And yet there is no shortage of scientific evidence. At the meeting, Dr Lynn Goldman (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD), presented data from the recently published Institute of Medicine (IOM) report that reviewed 11 studies looking at smoking bans in different regions and countries and showed that the bans were associated with consistently observed reductions in the risk of MI [1]. The benefit was observed early, often within a year of the ban being implemented.

"We concluded on the basis of the available literature that there is a causal relationship between smoking bans and decreases in acute coronary events," said Goldman during a WCC session on smoking and acute coronary event risk. "And I should say that this is a very high standard of evidence that the Institute of Medicine uses to actually say that a relationship is causal, and for us to have developed a consensus along that line, we really have very little doubt that there is an enormous benefit [to the bans]."

Banned From Smoking in Your Own Home

An essay in the June 17, 2010 issue of the New England Journal of Medicine suggests that smoke-free policies should extend to low-income public housing in the US, making it illegal for individuals living in these dwellings to smoke even in their own homes. [2]

Smoking bans in these multiunit apartments raises ethical concerns, according to authors Drs Jonathan Winickoff (Harvard Medical School, Boston, MA), Mark Gottlieb (Northeastern University School of Law, Boston), and Michelle Mello (Harvard School of Public Health, Boston), but is justified given harm caused by exposure to tobacco, the lack of other avenues of legal redress for nonsmoking residents of public housing, and the slow pace at which no-smoking policies have been implemented in public housing.

"The same legal, practical, and health issues that have driven successful efforts to make workplaces, private vehicles, and private housing smoke-free militate in favor of extending similar protection to the vulnerable public-housing population," write the authors.

Smoking and Heart Disease Enormous Burdens in Asia

Throughout the WCC conference, numerous sessions highlighted the impact of smoking and secondhand smoke on the global risk of cardiovascular disease. Dr Judith MacKay (University of Hong Kong), a policy advisor to the World Health Organization (WHO), stressed that coronary heart disease is an enormous burden in Asia, particularly in China. As documented throughout the meeting, there has been a large shift in the occurrence of cardiovascular disease in the past 50 years, with approximately 60% of the burden lying in low- and middle-income countries. In China alone, estimates suggest that more than three million people die annually from cardiovascular disease.

In even scarier news, MacKay noted that health professionals, despite knowing better, continue to smoke themselves. In China, home to one-third of the world's smokers, 30% of cardiologists smoke, while nearly 25% of individuals worldwide who are training to be a health professional, such as those in medical and nursing schools, also continue to smoke. "Our objectives are very simple," MacKay told the media. "It is to raise public and cardiologists' awareness of the connection between secondhand smoke and heart disease."

Those objectives are part of the efforts of several organizations, including the World Heart Federation, the Centers for Disease Control and Prevention (CDC), the World Lung Foundation, and Roswell Park Cancer Institute, to raise awareness about the cardiovascular risks of smoking and secondhand smoke. The group recently launched a campaign, one that includes the creation of a DVD--Warning: Secondhand Smoke is Hazardous to your Heart--exploring the link between cardiovascular problems and secondhand-smoke exposure. The new report includes many of the studies reported previously by heartwire and highlights a 2009 meta-analysis showing a 17% reduction in acute MI following the implementation of smoke-free laws.

Despite the sobering statistics, there was some good news presented at the WCC meeting. Dr David Wong (University of Hong Kong) presented data showing that the introduction of smoke-free legislation in Hong Kong led to a 28% spike in calls to a youth hotline set up to help adolescents quit smoking, as well as a 28% increase in the number of people who came in for counseling to quit. The data showed, however, that hitting teenagers in the pocketbook is the best way to compel them to quit smoking. After a significant 50% tax hike in 2009 on the cost of cigarettes, the number of calls to the "Youth Quitline" increased 144%, while 111% more teenagers came in for counseling to quit smoking.

The Need for Enforcement and Better Compliance

Most vital, however, in the global campaign against smoking is article 8 of the WHO Framework Convention on Tobacco Control (FCTC), which "commits governments to protecting their citizens from exposure to secondhand smoke in indoor public places and workplaces and public transport." The FCTC came into effect in 2005 and now has 169 parties that cover more than 80% of the world's population.

Presenting during a WCC session on the need to enhance the impact of smoke-free policies to reduce cardiovascular disease, Dr Armando Peruga (World Health Organization) pointed out that 43% of teenagers 13 years old to 15 years old are still living at home with smokers. Europe is the worst offender in this regard, said Peruga, with nearly 78% of 13- to 15-year-olds living at home with a smoker, while 51% of kids in Asia lived with a smoker.

During his presentation, Peruga noted that while 169 countries are parties to article 8, just 17 countries had policies in 2008 that provided universal, comprehensive, and effective protection from secondhand smoke, and only 5% of the population lives in a country with comprehensive, 100% smoke-free policies. The "gold-standard" smoke-free law, one where smoking is prohibited in all enclosed public places and workplaces, including bars, restaurants, and public transport, is rare, he noted, with compliance varying by sector. Hospitals and public transportation tend to most stringently adhere to the smoke-free policy, while bars and restaurants tend be more lax.

"Compliance is still an issue, and as we have been saying, passing a law, even a good law, a comprehensive law, is not enough," said Peruga. "We have always pointed out that enforcement requires small but critical resources. Anyone who forgets this is doomed to have these types of results, with relatively good laws on the books, but with low compliance."