SECONDHAND SMOKE EXPOSURE AND CARDIOVASCULAR EFFECTS

Making Sense of the Evidence

Committee on Secondhand Smoke Exposure and Acute Coronary Events

Board on Population Health and Public Health Practice

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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SECONDHAND SMOKE EXPOSURE AND CARDIOVASCULAR EFFECTS M a king Sense of the Evidence Committee on Secondhand Smoke Exposure and Acute Coronary Events Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 200-2005-13434, TO#11 between the National Academy of Sciences and the U.S. Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Secondhand smoke exposure and cardiovascular effects : making sense of the evidence / Committee on Secondhand Smoke Exposure and Acute Coronary Events, Board on Population Health and Public Health Practice. p. ; cm. Includes bibliographical references. ISBN 978-0-309-13839-0 (pbk.) 1. Coronary heart disease—Risk factors. 2. Passive smoking—Health aspects. I. Institute of Medicine (U.S.). Committee on Secondhand Smoke Exposure and Acute Coronary Events. [DNLM: 1. Cardiovascular Diseases—epidemiology. 2. Cardiovascular Diseases— prevention & control. 3. Occupational Exposure—legislation & jurisprudence. 4. Smoking—legislation & jurisprudence. 5. Tobacco Smoke Pollution—adverse effects. WG 120 S445 2009] RA645.H4S43 2009 616.1'2305—dc22 2009049617 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www. iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citiation: IOM (Institute of Medicine). 2010. Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence. Washington, DC: The National Acad- emies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON SECONDHAND SMOkE ExPOSuRE AND ACuTE CORONARy EvENTS Lynn R. Goldman, M.D., M.P.H. (Chair), Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD Neal Benowitz, M.D., Professor of Medicine, Psychiatry and Biopharmaceutical Sciences, Comprehensive Cancer Center, University of California, San Francisco Aruni Bhatnagar, Ph.D., Professor of Medicine and Distingushed University Scholar, Environmental Cardiology, University of Louisville, KY Francesca Dominici, Ph.D., Professor, Department of Biostatistics, Harvard School of Public Health, Harvard University, Boston, MA Stephen Fienberg, Ph.D., Maurice Falk University Professor of Statistics and Social Science, Department of Statistics, Carnegie Mellon University, Pittsburgh, PA Gary D. Friedman, M.D., M.S., Adjunct Investigator (former Director), Division of Research, Kaiser Permanente Medical Care Program of Northern California, and Consulting Professor of Epidemiology, Department of Health Research and Policy, Stanford University School of Medicine, Oakland, CA S. katharine Hammond, Ph.D., Chair and Professor, Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley Jiang He, M.D., Ph.D., Joseph S. Copes Chair and Professor, Department of Epidemiology, Tulane University, New Orleans, LA Suzanne Oparil, M.D., Director, Vascular Biology and Hypertension Program, and Professor of Medicine, Physiology and Biophysics, Division of Cardiovascular Disease, University of Alabama at Birmingham Eric Peterson, M.D., M.P.H., Duke Clinical Research Institute, Durham, NC Edward Trapido, Sc.D., M.S.P.H., FACE, Professor and Director, Global Research and Evaluation Center, Department of Epidemiology and Public Health, University of Miami, Miami, FL Staff Michelle C. Catlin, Ph.D., Study Director Rita Deng, M.H.S., Associate Program Officer Rose Marie Martinez, Sc.D., Director, Board on Population Health and Public Health Practice Raina Sharma, Senior Program Assistant Norman Grossblatt, Senior Editor v

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Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s (NRC’s) Report Review Com- mittee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Scott Appleton, Ph.D., Altria Client Services, Inc. John C. Bailar III, M.D., Ph.D., The University of Chicago Robert Brook, M.D., University of Michigan Health System Stanton A. Glantz, Ph.D., University of California, San Francisco School of Medicine Christopher B. Granger, M.D., Duke University Medical Center C. Arden Pope, M.S., Ph.D., Brigham Young University Peter Rosen, M.D., Beth Israel Deaconess Medical Center Jonathan M. Samet, M.D., M.S., Keck School of Medicine, University of Southern California Michael Siegel, M.P.H., M.D., Boston University School of Medicine Ponisseril Somasundaran, Ph.D., School of Engineering and Applied Science, Columbia University vii

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viii REVIEWERS Noel S. Weiss, M.D., Dr.P.H., School of Public Health and Community Medicine, University of Washington Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Floyd E. Bloom, M.D., The Scripps Research Institute, and Rogene F. Henderson, Ph.D., Lovelace Respiratory Research Institute. Appointed by the NRC, they were respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface The untimely death of a family member, friend, or coworker from acute cardiovascular events is a tragedy that repeats itself too many times each day. Overall age-adjusted mortality rates for heart disease have fallen significantly since the 1950s. Yet heart disease is still the leading cause of death in the United States. Ischemic heart disease killed nearly 424,900 people in the United States in 2006; or about half of the heart attacks that occurred that year. Largely we have been focused on prevention of ischemic heart disease at the individual level, through identification of genetic risk factors and modification of lifestyle factors such as diet and physical fitness. Chief among these has been smoking and the role that it has played both in chronic and acute cardiac diseases. More recently we have begun to appreciate that the environment plays a role. Years of careful research have elucidated a role for fine particulate air pollution formed from the combustion of fossil fuels in premature mor- tality due to cardiac disease. As smoking bans were put in place a number of researchers observed that there were reductions in hospital admissions and deaths due to acute cardiovascular events. In carrying out our research it became clear that, while we have learned much about why and how tobacco smoke and particulate air pollution aggravate cardiovascular disease, there is still much to learn. The paucity of information about cardiovascular toxicity of chemicals, even those in tobacco smoke, is indicative of the lack of attention that has been paid to environmental contributions to cardiovascular disease. ix

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x PREFACE It is hoped that our report will spur efforts to learn more. Too many people die prematurely each year to do otherwise. I am deeply appreciative of the expert work of our committee members: Neal Benowitz, Aruni Bhatnagar, Francesca Dominici, Steve Fienberg, Gary Friedman, Kathie Hammond, Jiang He, Suzanne Oparil, Eric Peterson, and Ed Trapido. This was an extraordinary group who each provided important contributions to the final report. It has been a privilege and a pleasure to work with the Institute of Medicine staff, study director Michelle Catlin and her excellent team Rita Deng and Raina Sharma, as well as Jennifer Saunders and Naoko Ishibe, Sc.D. Without them, this report would not have been possible. I thank those who provided expert presentations and background materials and gave us much to think about: Captain Matthew McKenna, M.D., M.P.H. and Darwin Labarthe, M.D., M.P.H., Ph.D., Cen- ters for Disease Control and Prevention; Stanton Glantz, Ph.D., University of California, San Francisco; Joel Kaufman, M.D., M.P.H., University of Washington, Seattle; Jon Samet, M.D., University of Southern California; Cynthia Hallett, American Nonsmokers’ Rights Foundation; and Jared Jobe, Ph.D., National Heart, Lung and Blood Institute of the National Insti- tutes of Health. In addition, I would like to thank individuals who assisted with the additional analyses of the committee: Aidan McDermott and How- ard Chang, both from the Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University. And, last, but certainly not least, I am appreciative of the time and effort offered by our reviewers, Floyd E. Bloom (monitor), Rogene F. Henderson (coordinator), Scott Appleton, John C. Bailar III, Robert Brook, Stanton A. Glantz, Christopher B. Granger, C. Arden Pope, Peter Rosen, Jonathan M. Samet, Michael Siegel, Ponisseril Somasundaran, and Noel S. Weiss. Lynn R. Goldman, Chair Committee on Secondhand Smoke Exposure and Acute Coronary Events

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Contents SUMMARY 1 1 INTRODUCTION 15 Charge to the Committee, 17 Committee’s Approach to Its Charge, 17 Sources of Uncertainty in Key Studies, 21 Organization of This Report, 26 References, 27 2 EVALUATING EXPOSURE TO SECONDHAND SMOKE 31 Constituents of Secondhand Smoke, 31 Measurement of Secondhand Smoke, 33 Exposures to Secondhand Smoke, 41 Conclusions, 53 References, 54 3 EXPERIMENTAL STUDIES RELEVANT TO THE PATHOPHYSIOLOGY OF SECONDHAND SMOKE 59 Effects of Cigarette Smoke, 61 Effects of Constituents of Cigarette Smoke, 71 Summary of Potential Modes of Action of Acute Coronary Events Due to Secondhand-Tobacco Smoke, 82 Conclusions, 83 References, 83 xi

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xii CONTENTS 4 EPIDEMIOLOGIC STUDIES OF SECONDHAND-SMOKE EXPOSURE AND CARDIOVASCULAR DISEASE 95 Risk Factors for Acute Coronary Events, 96 Epidemiology of Chronic Exposure to Secondhand-Tobacco Smoke in Relation to Coronary Heart Disease and Acute Coronary Events, 96 Conclusions, 104 References, 105 5 THE BACKGROUND OF SMOKING BANS 109 History of U.S. Smoking Policies, 109 Global Tobacco Policies, 114 Issues Surrounding Smoking Bans, 114 Conclusions, 121 References, 121 6 OVERVIEW OF KEY STUDIES OF THE EFFECTS OF SMOKING BANS ON ACUTE CORONARY EVENTS 125 Helena, Montana, 126 Italy, 133 Pueblo, Colorado, 147 Monroe County, Indiana, 149 Bowling Green, Ohio, 151 New York State, 153 Saskatchewan, Canada, 156 Scotland, 157 References, 160 7 SYNTHESIS OF KEY STUDIES EXAMINING THE EFFECT OF SMOKING BANS ON ACUTE CORONARY EVENTS 163 Limitations and Sources of Uncertainty in Key Studies, 163 Weight of Evidence from Key Studies, 194 Conclusions, 196 References, 197 8 CONCLUSIONS AND RECOMMENDATIONS 201 Summary of Report, 201 Summary of Overall Weight of Evidence, 207 Data Gaps and Research Recommendations, 217 Committee Responses to Specific Questions, 219 References, 224 Appendix AGENDAS OF PUBLIC MEETINGS 227