Burden of disease attributable to second-hand smoke exposure: A systematic review

Secondhand Smoke Exposure of Expectant Mothers in China: Factoring in the Role of Culture in Data Collection

Cancer is the leading cause of death worldwide. Tobacco smoking, including secondhand smoking, causes cancer and is responsible for over 22% of global cancer deaths. The adverse impacts of secondhand smoke are more pronounced for expectant mothers, and can deteriorate both mothers’ and infants’ health and well-being. Research suggests that secondhand smoke significantly increases expectant mothers’ risk of miscarriage, cancer, and other chronic disease conditions, and exposes their unborn babies to an increased likelihood of having life-long poor health. In China, a pregnant woman’s family members, such as her husband, parents, or in-laws, are the most likely people to be smoking around her. Due to traditional Chinese cultural practices, even though some expectant mothers understand the harm of secondhand smoke, they may be reluctant to report their family members’ smoking behaviors. Resulting in severe underreporting, this compromises health experts’ ability to understand the severity of the issue. This paper proposes a novel approach to measure secondhand smoke exposure of pregnant women in the Chinese context. The proposed system could act as a stepping stone that inspires creative methods to help researchers more accurately measure secondhand smoking rates of expectant mothers in China. This, in turn, could help health experts better establish cancer control measures for expectant mothers and decrease their cancer risk.

Spatiotemporal variability of exposure to secondhand smoke in Iran during 2009-2020: a systematic review

The present study aimed to provide a systematic review of studies on the prevalence of secondhand smoke (SHS) exposure in the Iran population as a serious indoor health hazard. A literature review of studies that considered SHS exposure, available in multiple electronic databases including Web of Science, PubMed, and Scopus published 2009-2020 in English and two Persian databases (SID and Magiran), was carried out following the PRISMA recommendations. A total of 55 studies were included based on the inclusion and exclusion criteria and the quality assessment. The results showed no specific decrease in the prevalence of exposure to secondhand smoke in Iran; however, it appeared that the exposure has been increasing. Distribution of studies in terms of age group revealed that most studies (38%) investigated adults (more than 18 years old), while 34% of the studies considered less than 18 years of age group and a single article considered infants (6-24 months). Based on the present study results, a large population of Iran was exposed to SHS. Moreover, based on Iran's STEPs 2016 (Stepwise Non-communicable Diseases Risk Factors Survey in Iran) study, the overall prevalence of SHS exposure at home (57.5%) was higher than in workplaces (49.2%). The results of the present study recommended that protection measures should be comprehensive in terms of exposure places, and since the exposure prevalence in some provinces was higher than the others, it is especially important to consider the local measures and cultural aspects in SHS control programs.

Trends in the Socioeconomic Inequalities Related to Second-Hand Smoke Exposure as Verified by Urine Cotinine Levels Among Nonsmoking Adults: Korea National Health and Nutrition Examination Survey 2008-2018

INTRODUCTION

The expansion of smoke-free policies has reduced the prevalence of second-hand smoke (SHS) exposure; however, declines differ according to socioeconomic positions. We evaluated the trends in socioeconomic inequalities related to SHS exposure in nonsmoking Korean adults from 2008 to 2018.

METHODS

We analyzed 30,027 nonsmoking adults from the Korea National Health and Nutrition Examination Survey 2008 to 2018. We evaluated trends in urine cotinine levels, self-reported prevalence of SHS exposure at workplaces and homes, and people exhibiting nonmeasurable urine cotinine levels between 2008 and 2018. To evaluate the yearly decline differences of urine cotinine levels according to socioeconomic positions, we calculated the interaction effects of year and education, household incomes, and occupation from linear regression analysis.

RESULTS

In the last 11 years, the geometric means of urine cotinine levels decreased from 3.53 (95% CI 2.96-4.19) ng/mL to 0.60 (0.57-0.64) ng/mL in males, and from 2.36 (2.03-2.73) ng/mL to 0.53 (0.51-0.56) ng/mL in females. The prevalence of SHS exposure at workplaces and homes also declined. In the multivariate model, the interaction effects between education and years were significant; therefore, indicating a substantial yearly decline of urine cotinine levels in higher educated individuals. The interaction effects between household incomes and years were only significant among males; the interaction effects between occupations and years were not significant.

CONCLUSIONS

SHS exposure in nonsmoking Korean adults has consistently decreased; however, socioeconomic inequalities related to SHS exposure by education level have widened. Policies targeting socioeconomically disadvantaged populations should be implemented to decrease the disparities of SHS exposure.

IMPLICATIONS

Along with tobacco control policies, the prevalence of self-reported and urinary cotinine verified SHS exposure has decreased in the last 11 years. In contrast, the socioeconomic inequalities related to SHS exposure by education level have increased over time. This study emphasizes the need for implementing tobacco control policies to reduce disparities of SHS exposure.

Secondhand smoke exposure in European countries with different smoke-free legislation. Findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behaviour in public places among smokers in six European countries and the influence of the country's type of smoking ban (partial or total ban) on such exposure and smoking behaviour.

METHODS

The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n=6,011) and 2018 (Wave 2, n=6,027). We used generalised estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and 1) self-reported SHS exposure, 2) self-reported smoking in public places.

RESULTS

A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (-5.1%; 95% CI: -8.0%;-2.2%). Self-reported smoking did not change significantly inside bars (22.7% in W2), restaurants (13.2% in W2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (OR=0.35; 95% CI: 0.26-0.47) in the countries with total bans as compared to those countries with partial bans.

CONCLUSION

The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places.

Associations between smoke-free vehicle legislation and childhood admissions to hospital for asthma in Scotland: an interrupted time-series analysis of whole-population data

BACKGROUND

In Scotland, childhood admissions to hospital for asthma fell from March, 2006, after legislation was introduced to prohibit smoking in public places. In December, 2016, new Scottish legislation banned smoking in vehicles containing a child. We aimed to determine whether the introduction of this new legislation produced additional benefits.

METHODS

We obtained data on all asthma emergency admissions to hospitals in Scotland between 2000 and 2018 for individuals younger than 16 years. We used interrupted time-series analyses to study changes in monthly incidence of asthma emergency admissions to hospital per 100 000 children after the introduction of smoke-free vehicle legislation, taking into account previous smoke-free interventions. We did subgroup analyses according to age and area deprivation, using the Scottish Index of Multiple Deprivation, and repeated the analyses for a control condition, gastroenteritis, and other respiratory conditions.

FINDINGS

Of the 32 342 emergency admissions to hospital for asthma among children younger than 16 years over the 19-year study period (Jan 1, 2000, to Dec 31, 2018), 13 954 (43%) were among children younger than 5 years and 18 388 (57%) were among children aged 5-15 years. After the introduction of smoke-free vehicle legislation, there was a non-significant decline in the slope for monthly emergency admissions to hospital for asthma among children younger than 16 years (-1·21%, 95% CI -2·64 to 0·23) relative to the underlying trend in hospital admissions for childhood asthma. However, children younger than 5 years had a significant decline in the slope for monthly asthma admissions (-1·49%, -2·69 to -0·27) over and above the underlying trend among children in this age group (equivalent to six fewer hospitalisations per year), but no such decline was seen in children aged 5-15 years. Monthly admissions to hospital for asthma fell significantly among children living in the most affluent areas (-2·27%, -4·41 to -0·07) but not among those living in the most deprived areas. We found no change in admissions to hospital for gastroenteritis or other respiratory conditions after the introduction of the smoke-free vehicle legislation.

INTERPRETATION

Although legislation banning smoking in vehicles did not affect hospital admissions for severe asthma among children overall or in the older age group, this legislation was associated with a reduction in severe asthma exacerbations requiring hospital admission among preschool children, over and above the underlying trend and previous interventions designed to reduce exposure to second-hand smoke. Similar legislation prohibiting smoking in vehicles that contain children should be adopted in other countries.

FUNDING

None.

Burden of disease from exposure to secondhand smoke in children in Europe

BACKGROUND

Secondhand smoke (SHS) exposure at home and fetal SHS exposure during pregnancy are a major cause of disease among children. The aim of this study is quantifying the burden of disease due to SHS exposure in children and in pregnancy in 2006-2017 for the 28 European Union (EU) countries.

METHODS

Exposure to SHS was estimated using a multiple imputation procedure based on the Eurobarometer surveys, and SHS exposure burden was estimated with the comparative risk assessment method using meta-analytical relative risks. Data on deaths and disability-adjusted life years (DALYs) were collected from National statistics and from the Global Burden of Disease Study.

RESULTS

Exposure to SHS and its attributable burden stalled in 2006-2017; in pregnant women, SHS exposure was 19.8% in 2006, 19.1% in 2010, and 21.0% in 2017; in children it was 10.1% in 2006, 9.6% in 2010, and 12.1% in 2017. In 2017, 35,633 DALYs among children were attributable to SHS exposure in the EU, mainly due to low birth weight.

CONCLUSIONS

Comprehensive smoking bans up to 2010 contributed to reduce SHS exposure and its burden in children immediately after their implementation; however, SHS exposure still occurs, and in 2017, its burden in children was still relevant.

IMPACT

Exposure to secondhand smoke at home and in pregnancy is a major cause of disease among children. Smoking legislation produced the adoption of voluntary smoking bans in homes; however, secondhand smoke exposure at home still occurs and its burden is substantial. In 2017, the number of deaths and disability-adjusted life years in children attributable to exposure to secondhand smoke in the European Union countries were, respectively, 335 and 35,633. Low birth weight caused by secondhand smoke exposure in pregnancy showed the largest burden. Eastern European Union countries showed the highest burden.

Children of Smoking and Non-Smoking Households' Perceptions of Physical Activity, Cardiorespiratory Fitness, and Exercise

Previous research has shown secondhand tobacco smoke to be detrimental to children’s health. This qualitative study aimed to explore children from low socioeconomic status (SES) families and their reasons for being physically active, attitudes towards physical activity (PA), fitness and exercise, perceived barriers and facilitators to PA, self-perceptions of fitness and physical ability, and how these differ for children from smoking and non-smoking households. A total of 38 children (9–11 years; 50% female; 42% smoking households) from the deprived areas of North West England participated in focus groups (n = 8), which were analysed by utilizing thematic analysis. The findings support hypothesised mediators of PA in children including self-efficacy, enjoyment, perceived benefit, and social support. Fewer than a quarter of all children were aware of the PA guidelines with varying explanations, while the majority of children perceived their own fitness to be high. Variances also emerged between important barriers (e.g., sedentary behaviour and environmental factors) and facilitators (e.g., psychological factors and PA opportunity) for children from smoking and non-smoking households. This unique study provided a voice to children from low SES and smoking households and these child perspectives could be used to create relevant and effective strategies for interventions to improve PA, fitness, and health.

Environmental Tobacco Smoke in Occupational Settings: Effect and Susceptibility Biomarkers in Workers From Lisbon Restaurants and Bars

Environmental tobacco smoke (ETS) has been recognized as a major health hazard by environmental and public health authorities worldwide. In Portugal, smoke-free laws are in force for some years, banning smoking in most indoor public spaces. However, in hospitality venues such as restaurants and bars, owners can still choose between a total smoke-free policy or a partial smoking restriction with designated smoking areas, if adequate reinforced ventilation systems are implemented. Despite that, a previous study showed that workers remained continuously exposed to higher ETS pollution in Lisbon restaurants and bars where smoking was still allowed, comparatively to total smoke-free venues. This was assessed by measurements of indoor PM2.5 and urinary cotinine, a biomarkers of tobacco smoke exposure, demonstrating that partial smoking restrictions do not effectively protect workers from ETS. The aim of the present work was to characterize effect and susceptibility biomarkers in non-smokers from those hospitality venues occupationally exposed to ETS comparatively to non-exposed ones. A group of smokers was also included for comparison. The sister chromatid exchange (SCE), micronucleus (MN) and comet assays in whole peripheral blood lymphocytes (PBLs) and the micronucleus assay in exfoliated buccal cells, were used as biomarkers of genotoxicity. Furthermore, a comet assay after ex vivo challenge of leukocytes with an alkylating agent, ethyl methanesulfonate (EMS), was used to analyze the repair capacity of those cells. Genetic polymorphisms in genes associated with metabolism and DNA repair were also included. The results showed no clear association between occupational exposure to ETS and the induction of genotoxicity. Interestingly, the leukocytes from non-smoking ETS-exposed individuals displayed lower DNA damage levels in response to the ex vivo EMS challenge, in comparison to those from non-exposed workers, suggesting a possible adaptive response. The contribution of individual susceptibility to the effect biomarkers studied was unclear, deserving further investigation.

In utero and early-life exposure to thirdhand smoke causes profound changes to the immune system

Acute lymphoblastic leukemia (ALL) is the most common cancer in children. Thirdhand smoke (THS) is the residual tobacco contamination that remains after the smoke clears. We investigated the effects of THS exposure in utero and during early life in a transgenic Cdkn2a knockout mouse model that is vulnerable to the development of leukemia/lymphoma. Female mice, and their offspring, were exposed from the first day of pregnancy to weaning. Plasma cytokines, body weight and hematologic parameters were measured in the offspring. To investigate THS exposure effects on the development of leukemia/lymphoma, bone marrow (BM) was collected from control and THS-exposed mice and transplanted into BM-ablated recipient mice, which were followed for tumor development for 1 year. We found that in utero and early-life THS exposure caused significant changes in plasma cytokine concentrations and in immune cell populations; changes appeared more pronounced in male mice. Spleen (SP) and BM B-cell populations were significantly lower in THS-exposed mice. We furthermore observed that THS exposure increased the leukemia/lymphoma-free survival in BM transplantation recipient mice, potentially caused by THS-induced B-cell toxicity. A trend towards increased solid tumors in irradiated mice reconstituted with THS-exposed BM stimulates the hypothesis that the immunosuppressive effects of in utero and early-life THS exposure might contribute to carcinogenesis by lowering the host defense to other toxic exposures. Our study adds to expanding evidence that THS exposure alters the immune system and that in utero and early-life developmental periods represent vulnerable windows of susceptibility for these effects.

Burden of disease from second-hand tobacco smoke exposure at home among adults from European Union countries in 2017: an analysis using a review of recent meta-analyses

Smoke-free legislation reduced second-hand smoke (SHS) exposure in public places, and indirectly promoted private smoke-free settings. Nevertheless, a large proportion of adults is still exposed to SHS at home. The aim of this paper is to quantify the burden of disease due to home SHS exposure among adults in the 28-European Union (EU) countries for year 2017. The burdens by gender from lung cancer, chronic obstructive pulmonary disease (COPD), breast cancer, ischemic heart disease (IHD), stroke, asthma, and diabetes were estimated in an original research analysis using the comparative risk assessment method. Relative risks of death/diseases by gender for adults exposed to SHS at home compared to not exposed ones were estimated updating existing meta-analyses. Prevalence of home SHS exposure by gender was estimated using a multiple imputation procedure based on Eurobarometer surveys. Data on mortality and disability adjusted life years (DALYs) were obtained from the Global Burden of Disease, Injuries and Risk Factors Study. In 2017, 526,000 DALYs (0.36% of total DALYs) and 24,000 deaths (0.46% of total deaths) were attributable to home SHS exposure in the 28-EU countries, mainly from COPD and IHD. South-Eastern EU countries showed the highest burden, with proportion of DALYs/deaths attributable to SHS exposure on total higher than 0.50%/0.70%, whereas northern EU-countries showed the lowest burden, with proportions of DALYs/deaths lower than 0.25%/0.34%. The burden from SHS exposure is still significant in EU countries. More could be done to raise awareness of the health risks associated with SHS exposure at home.

Secondhand smoke presence in outdoor areas in 12 European countries

INTRODUCTION

Secondhand smoke (SHS) causes morbidity and mortality among non-smokers.

OBJECTIVES

To investigate SHS presence in outdoor areas from 12 European countries and its association with country-level characteristics.

METHODS

Cross-sectional study performed in 2017-2018 within the TackSHS project. We conducted a face-to-face survey on a representative sample of the population aged 15 years and older from 12 European countries: Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania, and Spain. Out of 11,902 participants, 8,562 were non-smokers. SHS presence was assessed in selected outdoor areas and defined as respondents viewing someone smoking the last time they visited each setting within the last 6 months. A ranking score for outdoor SHS presence was assigned to each country based on the SHS presence in each setting. We used Spearman's correlation (r) and the Chi-squared tests to assess the relationship between SHS presence and country-level characteristics.

RESULTS

Except for children's playgrounds (39.5%; 95% confidence interval, CI: 37.6%-41.3%), more than half of non-smokers reported SHS presence in outdoor areas: schools (52.0%; 95%CI: 50.2%-53.7%), stadia (57.4%; 95%CI: 55.4%-59.4%), parks (67.3%; 95%CI: 66.0%-68.5%), hospitals (67.3%; 95%CI: 65.8%-68.7%), public transport stops (69.9%; 95%CI: 68.6%-71.2%), bar/restaurant terraces (71.4%; 95%CI: 70.2%-72.6%), and beaches (72.8%; 95%CI: 71.4%-74.1%). Residents in Latvia showed the highest overall outdoor SHS presence rank, followed by Greece, and Portugal. Outdoor SHS presence was directly correlated to the country's smoking prevalence (r = 0.64), and inversely correlated to the Tobacco Control Scale 2016 overall score (r = -0.62), the socio-demographic index 2017 (r = -0.56), and Gross Domestic Product per capita 2018 (r = -0.47) (p < 0.001).

CONCLUSIONS

SHS presence is high in most outdoor areas in Europe, especially in countries with higher smoking prevalence and lower tobacco control performance. To address outdoor SHS exposure, our findings require considering smoking bans along with other strategies to reduce smoking prevalence.

Surveillance systems for monitoring cervical cancer elimination efforts: Focus on HPV infection, cervical dysplasia, cervical screening and treatment

In order to achieve the global elimination of cervical cancer as a public health problem, close surveillance of progress in public health and clinical activities and outcomes across the three pillars of vaccination, screening and treatment will be required. Surveillance should ideally occur within an integrated system that is planned, funded, and regularly evaluated to ensure it is providing timely, accurate and relevant feedback for action. In this paper, we conceptualise the main public health surveillance objectives as process and outcome measures in each of the three pillars. Process measures include coverage/participation measures for vaccination, screening and treatment alongside the ongoing assessment of the quality and reach of these programs and activities. Outcome measures related to the natural history of human papillomavirus (HPV) infection include HPV infection prevalence, precursor cervical lesions and cervical cancers (including stage at diagnosis, cancer incidence and mortality). These outcome measures can be used for monitoring the effectiveness of the three core activities in the short, medium and long term to assess whether these interventions are effectively reducing their occurrence. We discuss possible methods for the surveillance of these measures in the context of country capacity, drawing from examples in Australia, the USA and in low and middle income countries.

Tobacco Use: A Major Risk Factor of Intracerebral Hemorrhage

Spontaneous intracerebral hemorrhage (sICH) is one of the deadliest subtypes of stroke, and no treatment is currently available. One of the major risk factors is tobacco use. In this article, we review literature on how tobacco use affects the risk of sICH and also summarize the known effects of tobacco use on outcomes following sICH. Several studies demonstrate that the risk of sICH is higher in current cigarette smokers compared to non-smokers. The literature also establishes that cigarette smoking not only increases the risk of sICH but also increases hematoma growth, results in worse outcomes, and increases the risk of death from sICH. This review also discusses potential mechanisms activated by tobacco use which result in an increase in risk and severity of sICH. Exploring the underlying mechanisms may help alleviate the risk of sICH in tobacco users as well as may help better manage tobacco user sICH patients.

Cigarette smoking exposure breaks the homeostasis of cholesterol and bile acid metabolism and induces gut microbiota dysbiosis in mice with different diets

Exposure of humans to second-hand smoking (SHS) increases glucose and lipid metabolic disorders. The link of hepatic metabolic dysfunction to environmental cigarette smoking has been noticed, but the related mechanism is still unclear. C57BL/6 mice with normal food diet (NFD) or high fat diet (HFD) were exposed to 15 min cigarette smoking twice a day in a 0.038 m³ box for 4 weeks, and the concentration of nicotine in the air of the box was 21.05 mg/m³ during the smoke exposure. Liver tissues and serum were collected for gene expression and biochemistry test. The fecal microbiota was also checked through 16S rDNA sequences. Cigarette smoking exposure increased the accumulation of total cholesterol (TC) in liver, and the expression of cholesterol synthesis-related genes was upregulated. The expression of CYP8B1 protein was significantly down-regulated, and the ratio of cholic acid (CA) to chenodeoxycholic acid (CDCA) was significantly reduced in the liver of mice exposed to cigarette smoking especially for HFD group. Cigarette smoking exposure caused insulin resistance in the liver of mice with HFD. The composition of the gut microbiota was altered with the exposure of cigarette smoking, and the change of the distribution of primary bile acids might be one of the reasons. It was concluded that cigarette smoking would break the homeostasis of cholesterol and bile acids metabolism and changed the composition of gut microbiota. Our discoveries confirmed that smoking bans are important for the public health.

Questionnaire-Based Environmental Tobacco Smoke Exposure and Hair Nicotine Levels in 6-month-old Infants: A Validation Study in Indonesia

Objectives. Using hair nicotine as the gold standard, this study aimed to establish cutoff points and validate the questionnaire-based environmental tobacco smoke (ETS) exposure and ETS statuses of Indonesian infants. Methods. A cross-sectional study design was conducted among families who were participants of the Peer Health Cohort Study in Jakarta, Indonesia. Households with 6-month-old infants joined this study. The presence and amount of ETS exposure were assessed by both questionnaire and hair sampling for nicotine determination. Head hair samples were collected from 102 infants and measured by optimized gas chromatography-mass spectrometry (GC/MS). Infants were grouped as ETS-exposed if they lived with at least 1 smoker at home. We used the receiver operating characteristic (ROC) curve to assess the sensitivity and specificity of cutoff values of hair nicotine. Results. There were 78 (76.5%) infants exposed to ETS based on the questionnaire. The nicotine concentrations in hair were significantly higher in infants with ETS exposure than in those without ETS exposure (P < .001). The area under the curve for nicotine was 0.774. A hair nicotine cutoff value of 2.37 ng/mg, with a sensitivity of 67.95% and specificity of 83.33%, was identified as the optimal cutoff value for separating exposed from non-exposed to ETS in infants. Conclusion. The hair nicotine value of infants aged 6 months is useful in confirming the questionnaire on smoking in the household and exposure to ETS. Moreover, it also could be used to distinguish ETS-exposed from non-ETS-exposed infants.

Early postnatal tobacco smoke exposure aggravates experimental autoimmune encephalomyelitis in adult rats

Although substantial evidence supports smoking as a risk factor for the development of multiple sclerosis (MS) in adulthood, it remains controversial whether early-life exposure to environmental tobacco smoke (ETS) increases the risk of MS later in life. Here, using experimental autoimmune encephalomyelitis (EAE) as an animal model for MS, we show that exposing neonatal rats during the first week (ETS1-EAE), but not the second week (ETS2-EAE) and the third week (ETS3-EAE) after birth, increased the severity of EAE in adulthood in comparison to pups exposed to filtered compressed air (AIR-EAE). The ETS1-EAE rats showed a worse neurological deficit score and a significant increase in CD4⁺ cell infiltration, demyelination, and axonal injury in the spinal cord compared to AIR-EAE, ETS2-EAE, and ETS3-EAE groups. Flow cytometry analysis showed that the ETS1 group had decreased numbers of regulatory T (Treg) cells and increased effector T (Teff) cells in the brain and spinal cord. The expressions of Treg upstream regulator Foxp3 and downstream cytokines such as IL-10 were also altered accordingly. Together, these findings demonstrate that neonatal ETS exposure suppresses Treg functions and aggravates the severity of EAE, confirming early-life exposure to ETS as a potential risk factor for multiple sclerosis in adulthood.

Prevention of Chronic Obstructive Pulmonary Disease

Governments could help prevent chronic obstructive pulmonary disease (COPD) by reducing smoking rates; for example, through tobacco sale restriction, increasing tobacco prices, reducing nicotine content, and banning smoking in public areas and workplaces. Smoking cessation in general, and in particular among patients with COPD, could be achieved through specific programs, including behavior modification and the use of nicotine replacement therapy, bupropion, or varenicline. Prevention and/or slowed COPD progression could be achieved by occupational exposure prevention; improved indoor/outdoor air quality; reduced cooking and heating pollutants; use of better stoves and chimneys, and alternative energy sources; and influenza and pneumococcal vaccination.

Dietary Factors and Tinnitus among Adolescents

The number of people suffering from constant tinnitus is ever-increasing and has spread to all age groups, including adolescents. The etiology of tinnitus is multifactorial, but dietary factors have been rarely investigated. The purpose of this study is to examine the relationship between dietary factors and constant tinnitus among adolescents from an urban environment. A population-oriented cross-sectional study was carried out during the 2019/2020 school year in 12 Belgrade secondary schools. There were 1287 school children aged from 15 to 19 years who participated in the study. There were 1003 respondents who completed a questionnaire on tinnitus (response rate 77.9%; 31% male). We used the standardized Tinnitus Screener questionnaire and a food frequency questionnaire specially designed for this study and adapted to Serbian adolescents. A logistic regression analysis revealed a strong negative correlation between fresh vegetables and fruits and tinnitus presence. On the other hand, the risk of constant tinnitus increased with the increased intake of white bread, carbonated beverages, and fast food. In conclusion, we show that fresh fruit and vegetable intakes may be negatively related to tinnitus frequency, while sweetened sodas, fast food, and white bread may raise the odds for tinnitus.

Implementing a context-driven awareness programme addressing household air pollution and tobacco: a FRESH AIR study

Most patients with chronic respiratory disease live in low-resource settings, where evidence is scarcest. In Kyrgyzstan and Vietnam, we studied the implementation of a Ugandan programme empowering communities to take action against biomass and tobacco smoke. Together with local stakeholders, we co-created a train-the-trainer implementation design and integrated the programme into existing local health infrastructures. Feasibility and acceptability, evaluated by the modified Conceptual Framework for Implementation Fidelity, were high: we reached ~15,000 Kyrgyz and ~10,000 Vietnamese citizens within budget (~€11,000/country). The right engaged stakeholders, high compatibility with local contexts and flexibility facilitated programme success. Scores on lung health awareness questionnaires increased significantly to an excellent level among all target groups. Behaviour change was moderately successful in Vietnam and highly successful in Kyrgyzstan. We conclude that contextualising the awareness programme to diverse low-resource settings can be feasible, acceptable and effective, and increase its sustainability. This paper provides guidance to translate lung health interventions to new contexts globally.

Association between indoor air pollution, tobacco smoke and tuberculosis: an updated systematic review and meta-analysis

OBJECTIVE

This study aims to further quantify evidence of the association between exposure to indoor air pollution (IAP), tobacco smoke etc., on the one hand and the risk of contracting tuberculosis (TB) on the other.

STUDY DESIGN

This was a systematic review and meta-analysis of articles published between June 2014 and February 2020 in PubMed, Web of Science, among others.

METHODS

We only included studies that controlled for confounders, screened both the exposed and unexposed study participants, and passive smoking studies that limited the study population to non-smokers. Quality of studies was assessed using the Newcastle-Ottawa scale. The analysis was conducted using STATA, and pooled effect sizes were calculated using the random-effects model, and heterogeneity was tested for using the Cochran Q test and I2 statistic.

RESULTS

A total of 26 articles were included in the final analysis. There was an increased risk of contracting TB among people exposed to IAP (risk ratio [RR] = 1.68, 95% confidence interval [CI] 1.108-2.542). We also observed a two-fold increase in the risk of contracting TB from exposure to secondhand tobacco smoke (RR = 2.15, 95%CI 1.419-3.242). Tobacco smoking doubled the risk of contracting TB (RR = 2.67, 95%CI 2.017-3.527). Furthermore, studies that used microbiological tests showed a higher RR compared to those that used other TB diagnostic methods.

CONCLUSION

Exposure to IAP and secondhand tobacco smoke increases the risk of contracting TB. Various disease prevention campaigns should include IAP awareness and encourage a shift to cleaner sources of energy.

Associations between a smoke-free homes intervention and childhood admissions to hospital in Scotland: an interrupted time-series analysis of whole-population data

BACKGROUND

Many children are exposed to second-hand smoke in the home and are at increased risk of asthma and other respiratory conditions. In Scotland, a public health mass-media campaign was launched on March 24, 2014, called Take it Right Outside (TiRO), with a focus on reducing the exposure of children to domestic second-hand smoke. In this study, our aim was to establish whether the TiRO campaign was followed by a decrease in hospital admissions for childhood asthma and other respiratory conditions related to second-hand smoke exposure across Scotland.

METHODS

For an interrupted time-series analysis, data were obtained on all hospital admissions in Scotland between 2000 and 2018 for children aged younger than 16 years. We studied changes in the monthly incidence of admissions for conditions potentially related to second-hand smoke exposure (asthma, lower respiratory tract infection, bronchiolitis, croup, and acute otitis media) per 1000 children following the 2014 TiRO campaign, while considering national legislation banning smoking in public spaces from 2006. We considered asthma to be the primary condition related to second-hand smoke exposure, with monthly asthma admissions as the primary outcome. Gastroenteritis was included as a control condition. The analysis of asthma admissions considered subgroups stratified by age and area quintile of the Scottish Index of Multiple Deprivations (SIMD).

FINDINGS

740 055 hospital admissions were recorded for children. 138 931 (18·8%) admissions were for respiratory conditions potentially related to second-hand smoke exposure, of which 32 342 (23·3%) were for asthma. After TiRO in 2014, we identified a decrease relative to the underlying trend in the slope of admissions for asthma (-0·48% [-0·85 to -0·12], p=0·0096) in younger children (age <5 years), but not in older children (age 5-15 years). Asthma admissions did not change after TiRO among children 0-15 years of age when data were analysed according to area deprivation quintile. Following the 2006 legislation, independent of TiRO, asthma admissions decreased in both younger children (-0·36% [-0·67 to -0·05], p=0·021) and older children (-0·68% [-1·00 to -0·36], p<0·0001), and in children from the most deprived (SIMD 1; -0·49% [-0·87 to -0·11], p=0·011) and intermediate deprived (SIMD 3; -0·70% [-1·17 to -0·23], p=0·0043) area quintiles, but not in those from the least deprived (SIMD 5) area quintile.

INTERPRETATION

Our findings suggest that smoke-free home interventions could be an important tool to reduce asthma admissions in young children, and that smoke-free public space legislation might improve child health for many years, especially in the most deprived communities.

FUNDING

University of Aberdeen Research Excellence Framework 2021 Impact Support Award Scheme.

Living with a Smoker and Multiple Health-Risk Behaviors

BACKGROUND

Behavioral medicine is showing growing theoretical and applied interest in multiple health-risk behaviors. Compared to engaging in a single health-risk behavior, multiple health-risk behaviors are linked to increased morbidity and mortality. A contextual determinant of multiple risk behaviors may be living with a smoker.

PURPOSE

This study investigated the role of living with a smoker in predicting multiple health-risk behaviors compared to a single health-risk behavior, as well as whether these multiple risk behaviors occur across both physical activity and dietary domains. Moreover, the study tested these effects across 3 years in longitudinal and prospective (controlling for health-risk behaviors at baseline) analyses.

METHODS

Participants were 82,644 women (age M = 63.5, standard deviation = 7.36, age range = 49-81) from the Women's Health Initiative Observational Study. Analyses used multinomial and binary logistic regression.

RESULTS

Living with a smoker was more strongly associated with multiple health-risk behaviors than with a single health-risk behavior. These multiple risk behaviors occurred across both physical activity and dietary domains. The effects persisted across 3 years in longitudinal and prospective analyses. Living with a smoker, compared to not living with a smoker, increased the odds of multiple health-risk behaviors 82% cross-sectionally and, across 3 years, 94% longitudinally and 57% prospectively.

CONCLUSIONS

These findings integrate research on multiple health-risk behaviors and on living with a smoker and underscore an unrecognized public health risk of tobacco smoking. These results are relevant to household-level interventions integrating smoking-prevention and obesity-prevention efforts.

Environmental Tobacco Smoke Exposure Estimated Using the SHSES Scale and Epicardial Adipose Tissue Thickness in Hypertensive Patients

The aim of the study was to assess the relationship between environmental tobacco smoke exposure (ETS) and epicardial adipose tissue thickness (EATT) in hypertensive patients. A total of 96 patients with essential hypertension were recruited for this study. The group consisted of 48 females and 48 males with the mean age of 69.32 ± 9.54 years. ETS was assessed with The Secondhand Smoke Exposure Scale (SHSES). EATT was assessed in 128-slice dual source coronary computed tomography angiography. In accordance to SHSES scale patients were divided into subgroups: subgroup A-no ETS exposure (SHSES = 0 points, n = 48), subgroup B-low ETS exposure (SHSES = 1-3 points, n = 11), subgroup C-medium ETS exposure (SHSES = 4-7 points, n = 20) and subgroup D-high ETS exposure (SHSES = 8-11 points, n = 17). Within the study group the mean EATT was 5.75 ± 1.85 mm and the mean SHSES score was 3.05 ± 3.74. EATT was statistically significantly higher in subgroup D than in subgroups A and B (A: 5.28 ± 1.64 mm, B: 5.04 ± 2.64 mm, D: 7.04 ± 2.64 mm, p_A-D and p_B-D < 0.05). There was a positive linear correlation between the exposure to ETS expressed by the SHSES scale and EATT (r = 0.44, p < 0.05). Regression analysis showed that higher SHSES score, higher BMI, and higher systolic and diastolic blood pressure are independent risk factors for higher EATT values. Contrary, the use of ACE inhibitors and β-blockers appeared to be independent protecting factor against higher EATT values. There is an unfavorable positive relationship between ETS exposure estimated using the SHSES scale and EATT in hypertensive patients.

A cross country comparison for the burden of cardiovascular disease attributable to tobacco exposure in China, Japan, USA and world

BACKGROUND

Tobacco exposure (TE) is the major contributor for CVD mortality, but few published studies on CVD mortality attributable to TE have analyzed the potential reasons underlying long-term trends in China. Our studysought to find the potential reasons and compared CVD mortality attributable to TE in China, Japan, the United States of America (USA), and the world between 1990 and 2017.

METHODS

The mortality data in China, Japan, the USA, and the world were obtained from Global Burden of Disease Study 2017(GBD 2017). Joinpoint regression was used to assess the trend magnitude and directions over time for CVD mortality, while the age-period-cohort method was used to analyzethe temporal trends of CVD mortality according to age, period, and cohort.

RESULTS

A significant downward trend was found in the age-standardised mortality rate (ASMR) of CVD attributable to smoking in four regions. China had the smallest decline and the Chinese ASMR became the highest in 2017. All the annual net drifts in the four regions were negative and the local drifts were below zero. The longitudinal age curves of CVD mortality attributable to smoking increased in four regions,with China having the largest increase. The period or cohort RRs indicated a decline, and China had the smallest decline. The researchers further analyzed the IHD and stroke trends, finding that the morality and period or cohort RR of IHD in China was always at a high level.

CONCLUSIONS

CVD mortality attributable to TE declined in four regions, and was highest in China. The proportion of IHD mortality attributable to TE was similar to stroke, which significantly changed the traditional cognition of CVD composition, but the control measure was not sufficient for IHD in China.

Knockout of macrophage migration inhibitory factor accentuates side-stream smoke exposure-induced myocardial contractile dysfunction through dysregulated mitophagy

Second hand smoke exposure increases the prevalence of chronic diseases partly attributed to inflammatory responses. Macrophage migration inhibitory factor (MIF), a proinflammatory cytokine, is involved in the pathogenesis of multiple diseases although its role in second hand smoke exposure-induced cardiac anomalies remains elusive. This study evaluated the impact of MIF knockout on side-stream smoke exposure-induced cardiac pathology and underlying mechanisms. Adult WT and MIF knockout (MIFKO) mice were placed in a chamber exposed to cigarette smoke for 1 h daily for 60 consecutive days. Echocardiographic, cardiomyocyte function and intracellular Ca²⁺ handling were evaluated. Autophagy, mitophagy and apoptosis were examined using western blot. DHE staining was used to evaluate superoxide anion (O₂^-) generation. Masson trichrome staining was employed to assess interstitial fibrosis. Our data revealed that MIF knockout accentuated side-stream smoke-induced cardiac anomalies in fractional shortening, cardiomyocyte function, intracellular Ca²⁺ homeostasis, myocardial ultrastructure and mitochondrial content along with overt apoptosis and O₂^- generation. In addition, unfavorable effects of side-stream smoke were accompanied by excessive formation of autophagolysosome and elevated TFEB, the effect of which was exacerbated by MIF knockout. Recombinant MIF rescued smoke extract-induced myopathic anomalies through promoting AMPK activation, mitophagy and lysosomal function. Taken together, our data suggest that MIF serves as a protective factor against side-stream smoke exposure-induced myopathic changes through facilitating mitophagy and autophagolysosome formation.