Environmental tobacco smoke and risk of respiratory cancer and chronic obstructive pulmonary disease in former smokers and never smokers in the EPIC prospective study

Darshika Christie-David and Chih-Hung Kuo

Medical Students (IV)

University of New South Wales ,
Community Medicine, Macarthur Health Service

In acknowledgement of
Dr. Nick Collins,
Staff Specialist,
Macarthur Ambulatory Care Service,
Campbelltown, NSW

EDITOR – In response to the article by Vineis et al(1), the EPIC
study provides further evidence for the real harm associated with passive
smoking. While medical attention has been drawn to this issue the public
needs to be further informed. Just as there are government and community
campaigns aimed at smokers to warn them of the detrimental effect of
smoking, there should similarly be warnings for non-smokers to increase
their awareness of the harm they are susceptible to because of their
smoker acquaintances.

The introduction of legislative restrictions against smoking in
environments where non-smokers are highly susceptible to harmful health
effects is vital to this cause. Public policy should be adopted to address
the issue of passive smoking by perhaps firstly directing attention to the
hospitality industry. Recently, this movement has become evident in
Australia where the New South Wales and Victoria governments have
introduced a law to ban smoking in pubs and bars.

Such policy should be based on scientific evidence of the harmful
effect of passive smoking, reinforced by several peripheral studies
supporting the change. For example, one study demonstrates that designated
smoking areas only provide a false sense of security and does not protect
the patrons in designated non-smoking areas from the harm(2). Furthermore,
the public support for banning smoking in pubs and clubs in Australia has
increased after the Sharp case(3) where a non-smoking employee
successfully established in court that her cancer was linked to years of
working in a smoky bar.

Opposition to such policy includes the potential financial impact on
the hospitality industry, loss of tax revenue from tobacco and the
violation of smokers’ right to ‘self-determination’. However, one study
showed that restaurants in Australia that prohibited smoking were not
affected in their operations by the change(4), and there is no evidence
yet to demonstrate that the impending hospitality industries will be
affected. The loss of tax revenue from tobacco might be compensated by the
reduction of health expenses related to secondary smoking and wellbeing of
the workers in bars and pubs.

Ethically, adopting appropriate bans on smoking in pubs and clubs can
be justified in terms of non-maleficence to non-smoking patrons and staff.
Though the decision to ban people from smoking when and where they desire
would deny them of their right to free will and autonomy, it would provide
ethical public policy and promote optimal community health. It may also
promote changes to social culture that has made smoking common-place in
these environments and with existing campaigns directed at smokers
encourage them to quit(5).

Considering the current evidence, the introduction of public
campaigns regarding passive smoke via such measures as prohibitions
against smoking in hospitality industries is quite legitimate. In
addition, the public has misconceptions about the health safety of
enjoying designated non-smoker areas and there should be increased
awareness about the real harm smokers are actually imposing on their
fellow citizen’s health.

1. Vineis P, Airoldi L, Veglia F et al. Environmental tobacco smoke
and risk of respiratory cancer and chronic obstructive pulmonary disease
in former smokers and never smokers in the EPIC prospective study. BMJ
2005; 330: 277-80

2. Cains T. Designated "no smoking" areas provide from partial to no
protection from environmental tobacco smoke. Tobacco Control 2004; 13(1):
17-22

3. Tzelepis F, Walsh R, Paul C. Community attitudes towards
environmental tobacco smoke in licensed premises: Follow-up study after
the Sharp case. Australian and New Zealand Journal of Public Health 2003;
27(5): 539-542

4. Chapman S, Borland R, Lal A. Has the ban on smoking in New South
Wales restaurants worked? A comparison of restaurants in Sydney and
Melbourne. MJA 2001; 174: 512-515

5. Fichtenberg C.M., Glantz S.A. Effect of smoke-free workplaces on
smoking behaviour: systematic review. BMJ 2002; 325: 188-91

Competing interests:
None declared

EDITOR— Any effort of Cuba in terms of tobacco reduction should be
accepted as more challenging than in any other country worldwide. Cuba,
the world's best known cigar-producing country, as BBC defined1, has a
special historical relationship to tobacco and suffers from relatively
high smoking rates. A new ban on smoking recently initiated is focused on
smoke-free policy and was designed to curb damage to people's health and
contribute to a change in public attitudes. A ban moves in the direction of the
Vineis et al paper on BMJ2, where the authors confirm that environmental
tobacco smoke is a risk factor for lung cancer and other respiratory
diseases, particularly in ex-smokers.

Although Cuban icon is Havanos Cigars, within the country, however,
cigarettes are used by 95% of regular smokers. Current rates of daily
tobacco use are 40% among men, peaking at 60% in middle-age. At younger
ages women have similar rates as men, however, there is little increase
with age and the average prevalence is around 25%. There is some evidence
of a decline in the last decade - in the same city the rates in 1992 were
44% in men and 33% in women.3

Just a day after the ban on smoking the Cuban people is wondering
how the rule will be accepted by smokers and how public transport, shops
and other closed spaces would become smoke-free. Cigarette smoking
represents the most urgent challenge for Cuba and these new campaigns need
the enthusiasm and vigor which have made other health interventions so
successful.

References:

1. Cuba, the world's best known cigar-producing country, has announced a
ban on smoking in some public places. BBC news UK edition. Wednesday, 19
January, 2005, 17:21 GMT

2. Vineis P, et al. Environmental tobacco smoke and risk of respiratory
cancer and chronic obstructive pulmonary disease in former smokers and
never smokers in the EPIC prospective study. BMJ 2005;330:277.

3. Cooper RS, Ordunez P, Iraola-Ferrer M, et al. Cardiovascular disease
and associated risk factors in Cuba: Prospects for prevention and control.
Am J Public Health. In press.

Pedro Ordúñez-García, MD..

Alfredo Espinosa Brito, MD, PhD.

Yanelis La Rosa Linares, MD

Department of Internal Medicine,
Hospital Gustavo Aldereguía Lima,
Cienfuegos 55 100. Cuba.

Competing interests:
None declared

The photograph on the BMJ issue showing the innocent child closing
his eyes and mouth as a response to the smoke reflects the natural dislike
of human body towards smoke.

This natural dislike reflected on the child`s face is added on by an
extensive evidence on the health hazards of passive smoking.Sufficient
data to implicate passive smoking as a cause of lung cancer and coronary
heart disease exists and a growing data implicating passive smoking as a
cause of stroke is accumulating. Hence the need is for global urgent
preventive and palliative measures. Various communities working on these
issues may very well consider on those lines. I strongly feel on the
following points:

1) Educating children in schools on health hazards of tobacco smoke.
2) Developing an antidote or a detoxifying substance to tobacco smoke or a
vaccine against ill-effects of tobacco smoke.
3) More aggressive and a regular publicity blitz on ill effects of
passive/active smoking.
4) More aggressive research to make smoke once exhaled to detoxify
immediately in air.
5) Ready availability of smoking cessation clinics to those who want to
stop smoking.
6) Also modifying National guidelines in terms of using nicotine patches
or inhalers who were unsuccessful in the past to stop smoking.

Lot of time and energies are being spent on doing various studies on
looking at ill effects of tobacco smoke on which a lot of convincing data
already exists.But if the same energies could also address some of the
above stated issues,it may be worth an energy spent.

Medical community should encourage every smoker to quit smoking and
it would be worth saying "NO success is final,no failure is fatal" for a
smoker in his efforts to stop smoking.

Competing interests:
None declared