Passive smoking as well as active smoking increases the risk of acute stroke

Effects of environmental tobacco smoke on adult rat brain biochemistry

Environmental tobacco smoke (ETS) has been linked to deleterious health effects, particularly pulmonary and cardiac disease; yet, the general public considers ETS benign to brain function in adults. In contrast, epidemiological data have suggested that ETS impacts the brain and potentially modulates neurodegenerative disease. The present study begins to examine yet unknown biochemical effects of ETS on the adult mammalian brain. In the developed animal model, adult male rats were exposed to ETS 3 h a day for 3 weeks. Biochemical data showed altered glial fibrillary acid protein levels as a main treatment effect of ETS, suggestive of reactive astrogliosis. Yet, markers of oxidative and cell stress were unaffected by ETS exposure in the brain regions examined. Increased proteolytic degradation of alphaII-spectrin by caspase-3 and the dephosphorylation of serine(116) on PEA-15 indicated greater apoptotic cell death modulated by the extrinsic pathway in the brains of ETS-exposed animals. Further, beta-synuclein was upregulated by ETS, a neuroprotective protein previously reported to exhibit anti-apoptotic and anti-fibrillogenic properties. These findings demonstrate that ETS exposure alters the neuroproteome of the adult rat brain, and suggest modulation of inflammatory and cell death processes.

Consequences of smoking during pregnancy on maternal health

OBJECTIVE

To estimate the incidence of maternal cardiovascular and pulmonary events and the prevalence of other comorbid conditions among pregnant smokers.

METHODS

We queried the Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ) for pregnancy-related discharge codes for the years 2000-2004. The prevalence of various conditions and the incidence of various complications were compared between smokers and nonsmokers.

RESULTS

The majority of smokers were young and white and had public insurance. Smokers were more likely to have experienced deep vein thrombosis (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1, 1.6), stroke (OR 1.7, 95% CI 1.2, 2.5), pulmonary embolus (OR 2.5, 95% CI 2.1, 3.0), and myocardial infarction (OR 4.6, 95% CI 3.3, 6.4). They were 3 times more likely to have experienced influenza or pneumonia (OR 2.9, 95% CI 2.7, 3.2) and 15 times more likely to have bronchitis (OR 15.2, 95% CI 12.8, 18.2). They were more likely to suffer from a number of comorbidities, including asthma (OR 4.0, 95% CI 3.7, 4.2) and gastrointestinal ulcers (OR 3.7, 95% CI 2.6, 5.5). Although they were less likely to have experienced gestational diabetes (OR 0.9, 95% CI 0.9, 1.0), preeclampsia (OR 0.8, 95% CI 0.8, 0.9), or eclampsia (OR 0.7, 95% CI 0.6, 0.9), they were more than 5 times as likely to have experienced an ectopic pregnancy (OR 5.4, 95% CI 4.6, 6.3).

CONCLUSIONS

Smoking has a negative impact on maternal health. Counseling about the risks of smoking in pregnancy should include not only fetal risks but maternal risks as well.

Age- and sex-specific trends in fatal incidence and hospitalized incidence of stroke in Scotland, 1986 to 2005

BACKGROUND

Temporal trends in stroke incidence are unclear. We aimed to examine age- and sex-specific temporal trends in incidence of fatal and nonfatal hospitalized stroke in Scotland from 1986 to 2005.

METHODS AND RESULTS

Mean age at the time of first stroke was 70.8 (SD, 12.9) years in men and 76.4 (12.9) years in women. Between 1986 and 2005, rates fell in men from 235 (95% CI, 229 to 242) to 149 (144 to 154) and in women from 299 (292 to 306) to 182 (177 to 188). Poisson modeling showed that temporal trends were influenced by age with declines in incidence of hospitalized stroke starting later in younger than older age groups. In both men and women aged under 55 years, the overall incidence rate of stroke was significantly higher in 2005 than in 1986.

CONCLUSIONS

We report in a whole country that the overall incidence of stroke declined steadily and substantially between 1986 and 2005, with a relative reduction in the risk of stroke of 31% in men and 42% in women. Reductions in rates of both hospitalized and nonhospitalized fatal stroke contributed to this overall decline. The increase in incident stroke rates in young people is of concern.

Evaluation of the Modeling of Exposure to Environmental Tobacco Smoke (ETS) in the SHEDS-PM Model

Environmental tobacco smoke (ETS) is estimated to be a major contributor to indoor PM concentration and human exposures to fine particulate matter of 2.5 microns or smaller (PM2.5). The Stochastic Human Exposure and Dose Simulation for Particulate Matter (SHEDS-PM) model developed by the US Environmental Protection Agency estimates distributions of outdoor and indoor PM2.5 exposure for a specified population based on ambient concentrations and indoor emissions sources. Because indoor exposures to ETS can be high, especially in indoor residential microenvironments, a critical assessment was conducted of the methodology and data used in SHEDS-PM for estimation of indoor exposure to ETS. For the residential microenvironment, SHEDS uses a mass-balance approach which is comparable to best practices. The default inputs in SHEDS-PM were reviewed and more recent and extensive data sources were identified. Sensitivity analysis was used to determine which inputs should be prioritized for updating. Data regarding the cigarette emission rate was found to be the most important. SHEDS-PM does not currently account for in-vehicle ETS exposure; however, in-vehicle ETS-related PM2.5 levels can exceed those in residential microenvironments by a factor of 10 or more. Therefore, a mass-balance based methodology for estimating in-vehicle ETS PM2.5 concentration is evaluated. Recommendations are made regarding updating of input data and algorithms related to ETS exposure in the SHEDS-PM model.

Smoke-free air policy: subcultural shifts and secondary health effects among club-going young adults

In March 2003, New York City implemented legislation that called for a ban of smoking in bars, restaurants, nightclubs, and other establishments. The express purpose of this legislation was to protect the health of employees and patrons from second-hand smoke. In addition to the stated goal of protection from second-hand smoke for employees, key secondary health effects of this law have emerged in the lives of club-going youth. This paper is based upon data derived from an ethnographic research project on club-related health issues in NYC. Drawing upon ethnographic fieldwork during the implementation of the ban and in-depth interviews with club-going youth, the paper provides a grounded analysis of youth reactions to the smoking ban and a descriptive profile of the secondary health effects of the smoking ban in nightclubs. It explores the attitudes of club-going youth towards the ban and the ways in which the legislation shapes the behaviours of habitual smokers, 'social smoking', and the use of drugs within bars and clubs. In particular, the data suggest a tension between the desire to remain subculturally involved and the desire to smoke. It also highlights the adaptive character of subcultures and the importance of social relations in behavioural patterns.

Epidemiology of ischemic and hemorrhagic stroke: incidence, prevalence, mortality, and risk factors

The epidemiology of ischemic and hemorrhagic stroke is an ongoing exploration to identify risk factors that continue to expand with the advent of technological advancements and preventative medical practices. Identification of risk factors that can or cannot be modified is a crucial step in determining stroke risk. Many of the modifiable risk factors are well established, and specific interventions to reduce stroke risk have been established. Some risk factors are less established, and intervention to reduce risk is yet to be determined by evidence-based medicine. Data from ongoing randomized clinical trials continue to enhance our ability to prevent a first stroke.

The control of environmental tobacco smoke: a policy review

According to World Health Organisation figures, 30% of all cancer deaths, 20% of all coronary heart diseases and strokes and 80% of all chronic obstructive pulmonary disease are caused by cigarette smoking. Environmental Tobacco Smoke (ETS) exposure has also been shown to be associated with disease and premature death in non-smokers. In response to this environmental health issue, several countries have brought about a smoking ban policy in public places and in the workplace. Countries such as the U.S., France, Italy, Ireland, Malta, the Netherlands, Sweden, Scotland, Spain, and England have all introduced policies aimed at reducing the population exposure to ETS. Several investigations have monitored the effectiveness of these smoking ban policies in terms of ETS concentrations, human health and smoking prevalence, while others have also investigated a number of alternatives to smoking ban policy measures. This paper reviews the state of the art in research, carried out in the field of ETS, smoking bans and Tobacco Control to date and highlights the need for future research in the area.

Risk factor management to prevent first stroke

This article provides an overview on the management of risk factors to prevent primary strokes, the gaps in successful management, and future directions for the research and management of stroke risk factors. The major focus is given to the management of modifiable risk factors for stroke, including hypertension, diabetes, dyslipidemia, atrial fibrillation and other cardiac conditions, carotid artery stenosis, smoking, poor diet, physical inactivity, and obesity. A brief discussion on the management of potentially modifiable risk factors, such as alcohol and drug abuse, sleep apnea, and hyperhomocysteinemia, is included, as is the use of antiplatelet therapy in primary stroke prevention. Finally, prognostic scores to assess an individual risk for a first stroke are reviewed.

Passive smoking and risk of peripheral arterial disease and ischemic stroke in Chinese women who never smoked

BACKGROUND

The association between secondhand smoke (SHS) and risk of peripheral arterial disease (PAD) and stroke remains uncertain.

METHODS AND RESULTS

We examined the relationship between SHS and cardiovascular diseases, particularly PAD and stroke, in Chinese women who never smoked from a population-based cross-sectional study in Beijing, China. SHS exposure was defined as exposure to another person's tobacco smoke at home or in the workplace. Cardiovascular disease events included coronary heart disease, stroke, and PAD. PAD was defined by signs of intermittent claudication as measured by the World Health Organization Rose questionnaire and an ankle-brachial index of <0.90. Among 1209 women who never smoked, 39.5% were exposed to SHS at home or in workplaces. Those individuals who were exposed to SHS had a significantly higher risk of coronary heart disease (adjusted odds ratio [OR], 1.69; 95% CI, 1.31 to 2.18) and ischemic stroke (OR, 1.56; 95% CI, 1.03 to 2.35) than those never exposed to SHS after adjustment for 13 potential risk factors. The adjusted ORs of PAD defined by intermittent claudication, by ankle-brachial index <0.90, and by either intermittent claudication or ankle-brachial index <0.90 were 1.87 (95% CI, 1.30 to 2.68), 1.47 (95% CI, 1.07 to 2.03), and 1.67 (95% CI, 1.23 to 2.16), respectively. Dose-response relationships were found between SHS exposure amount (cigarettes per day) and duration (minutes per day) and increasing prevalence of coronary heart disease, ischemic stroke, and PAD.

CONCLUSIONS

In China, SHS exposure in women is highly prevalent. In addition to being a risk factor for coronary heart disease, SHS should be considered an important risk factor for ischemic stroke and PAD in nonsmoking women.

Spousal smoking and incidence of first stroke: the Health and Retirement Study

BACKGROUND

Few prospective studies have investigated the relationship between spousal cigarette smoking and the risk of incident stroke.

METHODS

Stroke-free participants in the U.S.-based Health and Retirement Study (HRS) aged >or=50 years and married at baseline (n=16,225) were followed, on average, 9.1 years between 1992 and 2006) for proxy or self-report of first stroke (1,130 events). Participants were stratified by gender and own smoking status (never-smokers, former smokers, or current smokers), and the relationship assessed between the spouse's smoking status and the risk of incident stroke. Analyses were conducted in 2007 with Cox proportional hazards models. All models were adjusted for age; race; Hispanic ethnicity; Southern birthstate; parental education; paternal occupation class; years of education; baseline income; baseline wealth; obesity; overweight; alcohol use; and diagnosed hypertension, diabetes, or heart disease.

RESULTS

Having a spouse who currently smoked was associated with an increased risk of first stroke among never-smokers (hazard ratio=1.42, 95% CI=1.05, 1.93) and former smokers (hazard ratio=1.72, 95% CI=1.33, 2.22). Former smokers married to current smokers had a stroke risk similar to respondents who themselves smoked.

CONCLUSIONS

Spousal smoking poses important stroke risks for never-smokers and former smokers. The health benefits of quitting smoking likely extend to both the individual smoker and his or her spouse.

Lipid-soluble smoke particles upregulate vascular smooth muscle ETB receptors via activation of mitogen-activating protein kinases and NF-kappaB pathways

Cigarette smoke is a strong risk factor for cardiovascular disease. However, the underlying molecular mechanisms that lead to cigarette smoke-associated cardiovascular disease remain elusive. With functional and molecular methods, we demonstrate for the first time that lipid-soluble cigarette smoke particles (dimethylsulfoxide-soluble cigarette smoke particles; DSP) increased the expression of endothelin type B (ET(B)) receptors in arterial smooth muscle cells. The increased ET(B) receptors in arterial smooth muscle cells was documented as enhanced contractility (sensitive myograph technique), elevated levels of ET(B) receptor mRNA (quantitative real-time PCR), and protein expressions (immunohistochemistry and Western blotting). Intracellular signaling was studied with Western blotting and phosphoELISA; this revealed that DSP induced extracellular-regulated protein kinases 1 and 2 (ERK1/2), p38, and nuclear factor-kappaB (NF-kappaB) phosphorylation within 3 h. Blocking ERK1/2, p38, or NF-kappaB activation by their specific inhibitors significantly attenuated the DSP-induced upregulation of ET(B) receptor-mediated contraction and both ET(B) receptor mRNA and protein expression. In addition, dexamethasone abolished the DSP-induced upregulation of ET(B) receptor-mediated contraction. In conclusion, upregulation of ET(B) receptors by DSP in arterial smooth muscle cells involves activation of mitogen-activating protein kinases (ERK1/2 and p38) and the downstream transcriptional factor NF-kappaB pathways.

Exogenous heat shock protein-70 inhibits cigarette smoke-induced intimal thickening

Cigarette smoke is associated with increased carotid intimal thickening or stroke. Preliminary work showed that exposure to smoke resulted in a 4.5-fold reduction of heat shock protein-70 (HSP70) expression in spleens of mice using gene microarray analysis. In the current study, we investigated the role of extracellular HSP70 in carotid intimal thickening of mice exposed to cigarette smoke. Intimal thickening was induced by placement of a cuff around the right carotid artery of mice. Cuff injury resulted in increased HSP70 mRNA expression in carotid arteries that persisted for 21 days. Cigarette smoke exposure decreased arterial HSP70 expression and significantly increased intimal thickening compared with mice exposed to air. Treatment of mice exposed to cigarette smoke with intravenous recombinant HSP70 attenuated intimal thickening through reduced phosphorylated extracellular signal-regulated kinase (pERK) expression in the arterial wall. In vitro experiments with rat aortic smooth muscle cells confirmed that recombinant HSP70 decreases pERK and proliferating cell nuclear antigen (PCNA) expression in cells exposed to cigarette smoke extract and H(2)O(2). Our study suggests that decreased expression of arterial HSP70 is an important mechanism by which exposure to cigarette smoke augments intimal thickening. The effects of recombinant HSP70 suggest a role for extracellular HSP70.

Mortality attributable to passive smoking in Spain, 2002

OBJECTIVE

Exposure to environmental tobacco smoke (ETS) is associated with a variety of health effects, including lung cancer and ischaemic heart disease. The objective of this study was to estimate the number of deaths caused by exposure to ETS among non-smokers in Spain during the year 2002

METHODS

Prevalence of ETS exposure among never smokers was gathered from three region based health interview surveys. The relative risks of lung cancer and ischaemic heart diseases were selected from three meta-analyses. Population attributable risk (PAR) was computed using a range of prevalences (minimum-maximum). The number of deaths attributable to ETS was calculated by applying PARs to mortality not attributable to active smoking in 2002. The analyses were stratified by sex, age and source of exposure (home, workplace and both combined). In addition, a sensitivity analysis was performed for different scenarios.

RESULTS

Among men, deaths attributable to ETS ranged from 408 to 1703. From 247 to 1434 of these deaths would be caused by the exposure only at home, 136-196 by exposure only in the workplace and 25-73 by exposure at both home and the workplace. Among women, the number of attributable deaths ranged from 820 to 1534. Between 807 and 1477 of these deaths would be caused by exposure only at home, 9-32 by exposure only in the workplace and 4-25 by exposure both at home and in the workplace.

CONCLUSION

Exposure to ETS at home and at work in Spain could be responsible for 1228-3237 of deaths from lung cancer and ischaemic heart disease. These data confirm that passive smoking is an important public health problem in Spain that needs urgent attention.

Disease burden of adult lung cancer and ischaemic heart disease from passive tobacco smoking in China

OBJECTIVE

To address the health hazards tobacco smoking imposes upon non-smokers in China, this paper estimates the burden of diseases in adults from passive tobacco smoking for two major diseases--lung cancer and ischaemic heart disease (IHD).

METHODS

The disease burden was estimated in terms of both premature mortality and disability adjusted life years (DALYs), a measure that accounts for both the age at death and the severity of the morbidity.

RESULTS

Passive smoking caused more than 22,000 lung cancer deaths in 2002 according to these estimates. When the toll of disability is added to that of mortality, passive smoking was responsible for the loss of nearly 230,000 years of healthy life from lung cancer. Using the evidence from other countries that links IHD to passive smoking, we estimated that approximately 33,800 IHD deaths could be attributable to passive smoking in China in 2002. Passive smoking is also responsible for the loss of more than one quarter of a million years of healthy life from IHD. Although most of the disease burden caused by active smoking occurs among men, women bear nearly 80% of the total burden from passive smoking. The number of deaths among women caused by passive smoking is about two-thirds of that caused by smoking for the two diseases we examined.

CONCLUSION

Even without considering the passive smoking risks for other diseases and among children that have been documented in other countries, passive smoking poses serious health hazards for non-smokers, especially for adult female non-smokers in China, adding more urgency to the need for measures to be taken immediately to protect the health of non-smokers and curb the nation's tobacco epidemic.

Diversity of risk factors for stroke: The putative roles and mechanisms of depression and air pollution

Several conventional risk factors for stroke and cerebrovascular disease, such as hypertension, smoking, and atrial fibrillation, are widely recognized. Correct management of these modifiable factors significantly reduces stroke risk. We review the research evidence that depressive symptoms and increased atmospheric pollution are associated with an increased risk of stroke, and outline putative mechanisms that may account for these associations. The data on depression and stroke risk strongly indicate the need for treatment intervention studies. The design and implementation of intervention studies related to air pollution requires better understanding of the pathophysiologic mechanisms linking exposures to the onset of stroke.

Declines in hospital admissions for acute myocardial infarction in New York state after implementation of a comprehensive smoking ban

OBJECTIVES

Reductions in exposure to environmental tobacco smoke have been shown to attenuate the risk of cardiovascular disease. We examined whether the 2003 implementation of a comprehensive smoking ban in New York State was associated with reduced hospital admissions for acute myocardial infarction and stroke, beyond the effect of moderate, local and statewide smoking restrictions, and independent of secular trends.

METHODS

We analyzed trends in county-level, age-adjusted, monthly hospital admission rates for acute myocardial infarction and stroke from 1995 to 2004 to identify any association between admission rates and implementation of the smoking ban. We used regression models to adjust for the effects of pre-existing smoking restrictions, seasonal trends in admissions, differences across counties, and secular trends.

RESULTS

In 2004, there were 3813 fewer hospital admissions for acute myocardial infarction than would have been expected in the absence of the comprehensive smoking ban. Direct health care cost savings of $56 million were realized in 2004. There was no reduction in the number of admissions for stroke.

CONCLUSIONS

Hospital admission rates for acute myocardial infarction were reduced by 8% as a result of a comprehensive smoking ban in New York State after we controlled for other relevant factors. Comprehensive smoking bans constitute a simple, effective intervention to substantially improve the public's health.

Environmental vascular risk factors: new perspectives for stroke prevention

Despite intensive evaluation of acute stroke patients, perhaps only half of the attributable stroke risk is usually identified. In addition to traditional and non-traditional vascular risk factors-including most recently homocysteine, inflammation, and alterations of coagulation-a number of environmental risk factors for stroke have been identified in the last decade. In this update we review the following: lower education and poor socioeconomic status (probable surrogates for exposure to traditional high-risk behaviors such as smoking, poor nutrition, lack of prenatal control, absence of preventive medical and dental care, and non-compliance of treatment of conditions such as hypertension); depression, stress and affective disorders; obstructive sleep apnea; passive smoking and environmental pollution; infections, in particular periodontal diseases that increase C-reactive protein (CRP); raised body mass index (obesity); exercise, and diet. The possible role of high-fructose corn syrup in the epidemic of obesity in the USA is reviewed. Protective diets include higher consumption of fish, olive oil, grains, fruits and vegetables (Mediterranean diet), as well as probiotic bacteria in yogurt and dairy products. Careful attention should be given to the patient's environment looking for modifiable factors. The effects of clean environmental air and water, adequate diet and appropriate nutrition, healthy teeth, exercise, and refreshing sleep in the prevention of stroke and cardiovascular disease appear to be quite compelling. Although some of these modifiable risk factors lack evidence-based information, judicious clinical sense should be used to counteract the potentially damaging effects of adverse environmental vascular risk factors.

Selective hair analysis of nicotine by molecular imprinted solid-phase extraction: An application for evaluating tobacco smoke exposure

A method using a molecularly imprinted polymer (MIP) as the selective sorbent for solid-phase extraction (SPE) has been developed. Its application to the assay of hairy nicotine level among smokers and non-smokers with high-performance liquid chromatography (HPLC) and evaluation of exposures to the environmental tobacco smoke (ETS) were validated. The MIP was synthesized using nicotine as the template molecule and methacrylic acid (MAA) as the functional monomer. This MIP-SPE method provided inherent selectivity and a sensitive response to nicotine with a detection limit of 0.2 ng/ml hair at a signal-to-noise ratio of 3:1 and the limit of quantification was 0.5 ng/ml. The linearity was assessed in the range of 0.5-80 ng/ml hair, with a coefficient (r(2)) greater than 0.987. The amounts of nicotine determined in smokers and non-smokers hair were in the range of 5.1-69.5 ng/mg hair and 0.50-9.3 ng/mg hair, respectively. The reported measures of ETS exposure were significantly associated with hairy nicotine levels. This assay of nicotine in hair using MISPE provided a very selective and reliable method for the evaluation of the exposure to tobacco smoke.

Decline in respiratory symptoms in service workers five months after a public smoking ban

OBJECTIVE

To evaluate the effect of a total ban on smoking indoors in restaurants and other hospitality business premises in Norway, on respiratory symptoms among workers in the industry.

METHODS

Phone interviews with 1525 employees in the hospitality business were conducted immediately before the enacting of the law. In a follow-up study five months later, 906 of the workers from the baseline sample participated. Questions were asked on demographic variables, passive smoking exposure, personal smoking, attitudes towards the law, and five respiratory symptoms. Change in symptom prevalence was analysed with McNemar's test and with analysis of variance (ANOVA) for repeated measures.

RESULTS

The prevalence of all five symptoms declined after the ban; for morning cough from 20.6% to 16.2% (p < 0.01); for daytime cough from 23.2% to 20.9%; for phlegm cough from 15.3% to 11.8% (p < 0.05); for dyspnoea from 19.2% to 13.0% (p < 0.01); and for wheezing from 9.0% to 7.8%. ANOVA showed that the largest decline in symptom prevalence was seen among workers who themselves gave up smoking, and subjects with a positive attitude towards the law before it took effect.

CONCLUSION

A significant decrease in respiratory symptoms among service industry workers was found five months after the enacting of a public smoking ban.

Intensive management of risk factors for accelerated atherosclerosis: the role of multiple interventions

Patients at high risk of vascular events can reduce their risk by 75% to 80% through a combination of lifestyle changes and medical therapy. These include smoking cessation, a Mediterranean diet, daily exercise, maintaining a fit weight, moderate consumption of alcohol, effective control of blood pressure and diabetes, intensive treatment with lipid-lowering drugs and antiplatelet agents, and perhaps treatment with vitamins to lower homocysteine. Much of this is achieved primarily by the patient; physicians need to become better at assisting their patients in making lifestyle changes. Effective control of treatment-resistant hypertension can be improved by individualizing medical therapy to the underlying cause, based on measurement of plasma renin and aldosterone. Measurement of carotid plaque may be useful by providing feedback on the success of therapy.

Environmental Tobacco Smoke Exposure and Risk of Stroke in Nonsmokers: A Review With Meta-analysis

Our objective was to provide a comprehensive review of the epidemiologic evidence relating stroke to exposure to environmental tobacco smoke (passive smoking) in lifelong nonsmokers. In all, 7 prospective, 6 case-control, and 3 cross-sectional studies were identified that provided relevant information. The 16 studies varied considerably in design, exposure indices used, and disease definition. Based on 24 sex-specific relative risk estimates, and using current spousal exposure (or nearest equivalent) as the exposure index, meta-analysis gave an overall estimate of 1.25 (95% confidence interval 1.16-1.36), with no significant heterogeneity. There was no significant heterogeneity by sex, year of publication, fatality, or disease end point. There was some indication that relative risks were less elevated in prospective studies and in US or European studies. No elevation was seen for subarachnoid hemorrhage. The estimate was similar using ever rather than current exposure, or total rather than spousal exposure. Adjustment for risk factors other than age had no material effect on the estimate. Eight studies provided dose-response estimates, the combined relative risk for the highest level of exposure being 1.56 (95% confidence interval 1.34-1.82). Many studies have evident weaknesses, and recall bias and particularly publication bias are major concerns. Currently, the association is only suggestive of a possible causal relationship. A clearer picture could be obtained using data from existing very large prospective studies that have already provided risk estimates for passive smoking and heart disease, and by conducting large, well-designed studies of incident stroke.

Potential new risk factors for ischemic stroke: what is their potential?

BACKGROUND AND PURPOSE

About 60% to 80% of all ischemic strokes can be attributed to increasing blood pressure, blood cholesterol, cigarette smoking, carotid stenosis, and diabetes mellitus (atherosclerotic ischemic stroke), and atrial fibrillation and valvular heart disease (cardiogenic ischemic stroke). The aim of this review was to examine the potential role of other risk factors in the etiology of ischemic stroke.

SUMMARY OF REVIEW

About 10% to 20% of atherosclerotic ischemic strokes can probably be attributed to recently established, causal risk factors for ischemic heart disease: raised apoB/apoA 1 ratio, obesity, physical inactivity, pyschosocial stress and low fruit and vegetable intake. However, their causal role remains to be proven. The direct genetic contribution of any single gene towards ischemic stroke is likely to be modest and apply in selected patients only and in combination with environmental factors or via other epistatic (gene-gene or gene-environmental) effects.

CONCLUSIONS

Research resources should not be allocated disproportionately to emerging novel risk factors that may account for up to only 20% of all strokes at the expense of researching the determinants of the relatively few established causal factors that account for up to 80% of all strokes.

Primary Prevention of Ischemic Stroke

Background and Purpose— This guideline provides an overview of the evidence on various established and potential stroke risk factors and provides recommendations for the reduction of stroke risk.

Methods— Writing group members were nominated by the committee chair on the basis of each writer’s previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee. The writers used systematic literature reviews (covering the time period since the last review published in 2001 up to January 2005), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations based on standard American Heart Association criteria. All members of the writing group had numerous opportunities to comment in writing on the recommendations and approved the final version of this document. The guideline underwent extensive peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

Results— Schemes for assessing a person’s risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to their potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic factors. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, alcohol abuse, drug abuse, oral contraceptive use, sleep-disordered breathing, migraine headache, hyperhomocysteinemia, elevated lipoprotein(a), elevated lipoprotein-associated phospholipase, hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

Conclusion— Extensive evidence is available identifying a variety of specific factors that increase the risk of a first stroke and providing strategies for reducing that risk.

Exposure of pre-school children to passive cigarette and narghile smoke in Beirut

BACKGROUND

Narghile is a resurging smoking device. However, little research has been done to assess passive smoking exposure. The objective of the present study is to evaluate the exposure of pre-school age children in Beirut to parental passive smoking from cigarette and/or narghile.

METHODS

Data were collected from 1057 pre-school age children attending 16 day cares and 7 nursery schools in the city of Beirut.

RESULTS

The overall prevalence of parental smoking (cigarette and/or narghile) was 53.3%. Ten per cent of respondents reported smoking only narghile. Fathers were significantly more likely than mothers to smoke cigarettes. However, there was no significant difference between fathers and mothers with respect to smoking narghile only. Education was a significant predictor for smoking cigarettes but not for smoking narghile.

CONCLUSION

Narghile smoking appears to follow different gender and social patterns than cigarette smoking. Further research is needed to establish the determinants of narghile smoking, in order to develop adequate prevention policies.

Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches for the implementation of guidelines and their use in high-risk populations.

Consultation après un infarctus ou un hématome cérébral

Hypertension is the principal risk factor for cerebral infarctions and intracerebral hematoma. The brain is the principal target of hypertension. The brain is the principal target of antihypertensive drugs. Controlling blood pressure and stopping smoking reduces the risk of cerebral infarction by 40%. Objectives of a consultation after cerebral infarction or intracerebral hematoma: validate diagnosis and cause, identify risk factors for recurrent cerebral infarction but also for myocardial infarction and lower limb arterial disease, begin treatment of the risk factors for recurrence, begin prevention of atherothrombotic complications and embolic heart disease, identify complications of cerebral infarction and intracerebral hematoma.

Effects of the smoking ban on benzene and 1,3-butadiene levels in pubs in Dublin

According to World Health Organisation figures, 30% of all cancer deaths, 20% of all coronary heart diseases and strokes and 80% of all chronic obstructive pulmonary disease are caused by cigarette smoking. In accordance with the recommendations of the Tobacco Free Policy Review Group Report the Irish government has introduced a smoking ban in all workplaces with the exception of prisons and psychiatric hospitals. This study measured the levels of benzene and 1,3-butadiene in air, two known carcinogens and environmental tobacco smoke (ETS) markers, in pubs both before and after the smoking ban was introduced. The results of the study have quantified the significant gross differences in pre and post ban exposure levels. The International Commission on Radiological Protection (ICRP), Human Respiratory Tract model for Radiological Protection has then been adopted to assess the amounts of these pollutants typically absorbed in the nose, throat and lungs of the workers and patrons of pubs in Ireland before and after the smoking ban. This has revealed a reduction in the average dose of benzene and 1,3-butadiene of 91% and 95% respectively for a typical three hour exposure in Irish pub.

Tobacco smoke chemicals attenuate brain-to-blood potassium transport mediated by the Na,K,2Cl-cotransporter during hypoxia-reoxygenation

Smoking tobacco, including cigarettes, has been associated with an increased incidence and relative risk for cerebral infarction in both men and women. Recently, we have shown that nicotine and cotinine attenuate abluminal (brain facing) K(+) uptake mediated by the Na,K,2Cl-cotransporter (NKCC) in bovine brain microvessel endothelial cells (BBMECs) after hypoxic/aglycemic exposure (stroke conditions). The purpose of the current study was to explore the effects of nicotine and tobacco smoke chemicals on K(+) movement through the blood-brain barrier during both hypoxia/aglycemia and reoxygenation. BBMECs were exposed to nicotine/cotinine, nicotine-containing cigarette smoke extract (N-CSE), or nicotine-free cigarette smoke extract (NF-CSE) in quantities designed to mimic plasma concentrations of smokers. Stroke conditions were mimicked in vitro in BBMECs through 6 h of hypoxia/aglycemia with or without 12 h of reoxygenation, after which NKCC-mediated K(+) uptake and paracellular integrity were measured with (86)Rb and [(14)C]sucrose, respectively. In addition, K(+) concentrations in brain extracellular fluid were estimated in (86)Rb-injected rats that were administered nicotine, N-CSE, or NF-CSE and on whom global ischemia/reperfusion by in vivo four-vessel occlusion was performed. Both in vitro and in vivo paradigms showed nicotine, the major alkaloid present in tobacco smoke, to be the determining factor of an inhibited response of abluminal NKCC in BBMECs during and after stroke conditions. This was measured as a decrease in abluminal brain endothelial cell NKCC activity and as an increase in brain extracellular K(+) concentration measured as the brain extracellular fluid (86)Rb/plasma ratio after in vivo four-vessel occlusion with reperfusion.

Early evidence on the effectiveness of clean indoor air legislation in New York State

In July 2003, New York State implemented the Clean Indoor Air Act (CIAA) to reduce exposure to environmental tobacco smoke (ETS). In this cross-sectional study, workers (n=168) completed an interview assessing ETS exposure and provided urine for cotinine analysis. Hospitality workers recruited after implementation of the CIAA had significant reductions in ETS exposure and urine cotinine, compared with those recruited before implementation. The New York State CIAA yielded measurable reductions in ETS exposure for hospitality workers.

Changes in hospitality workers' exposure to secondhand smoke following the implementation of New York's smoke-free law

OBJECTIVE

To assess the impact on hospitality workers' exposure to secondhand smoke of New York's smoke-free law that prohibits smoking in all places of employment, including restaurants, bars, and bowling facilities.

DESIGN

Pre-post longitudinal follow up design.

SETTINGS

Restaurants, bars, and bowling facilities in New York State.

SUBJECTS

At baseline, 104 non-smoking workers in restaurants, bars, and bowling facilities were recruited with newspaper ads, flyers, and radio announcements. Of these, 68 completed a telephone survey and provided at least one saliva cotinine specimen at baseline. At three, six, and 12 month follow up studies, 47, 38, and 32 workers from the baseline sample of 68 completed a telephone survey and provided at least one saliva cotinine specimen.

INTERVENTION

The smoke-free law went into effect 24 July 2003.

MAIN OUTCOME MEASURES

Self reported sensory and respiratory symptoms and exposure to secondhand smoke; self administered saliva cotinine specimens. Analyses were limited to subjects in all four study periods who completed a telephone survey and provided at least one saliva cotinine specimen.

RESULTS

All analyses were limited to participants who completed both an interview and a saliva specimen for all waves of data collection (n = 30) and who had cotinine concentrations < or = 15 ng/ml (n = 24). Hours of exposure to secondhand smoke in hospitality jobs decreased from 12.1 hours (95% confidence interval (CI) 8.0 to 16.3 hours) to 0.2 hours (95% CI -0.1 to 0.5 hours) (p < 0.01) and saliva cotinine concentration decreased from 3.6 ng/ml (95% CI 2.6 to 4.7 ng/ml) to 0.8 ng/ml (95% CI 0.4 to 1.2 ng/ml) (p < 0.01) from baseline to the 12 month follow up. The prevalence of workers reporting sensory symptoms declined from 88% (95% CI 66% to 96%) to 38% (95% CI 20% to 59%) (p < 0.01); there was no change in the overall prevalence of upper respiratory symptoms (p < 0.16).

CONCLUSION

New York's smoke-free law had its intended effect of protecting hospitality workers from exposure to secondhand smoke within three months of implementation. One year after implementation, the results suggest continued compliance with the law.

Passive cigarette smoking increases isoprostane formation

Passive smoking has been demonstrated to exert a variety of deleterious effects eventually resulting in vascular damage. Isoprostanes, a reliable marker of in vivo oxidation injury, have been shown to increase in active cigarette smoking. Data for passive smoking are lacking. We were examining the isoprostane 8-epi-PGF2alpha in 12 smokers and non-smokers exposed daily to passive cigarette smoke for 12 days. Plasma samples stored at liquid nitrogen from people having been examined earlier were used. Prevalues of 8-epi-PGF2alpha are higher in cigarette smokers. Exposure to passive smoking causes a significant increase in 8-epi-PGF2alpha in non-smokers, while in smokers there is only a trendwise increase. After repeated passive smoke exposure, 8-epi-PGF2alpha in non-smokers approaches the respective values of smokers. There is a significant correlation of 8-epi-PGF2alpha to the thromboxane (plasma, serum, conversion from exogenous precursor, 11-dehydro-TXB2) parameters (MDA, HHT- conversion) examined in these patients before. The findings document a significant temporary increase in in vivo oxidation injury due to passive smoke favouring development and/or progression of vascular disease.

Hazardous waste sites and stroke in New York State

BACKGROUND

Environmental exposure to persistent organic pollutants (POPs) may lead to elevation of serum lipids, increasing risk of atherosclerosis with thromboembolism, a recognized cause of stroke. We tested the hypothesis that exposure to contaminants from residence near hazardous waste sites in New York State influences the occurrence of stroke.

METHODS

The rates of stroke hospital discharges were compared among residents of zip codes containing hazardous waste sites with POPs, other pollutants or without any waste sites using information for 1993-2000 from the New York Statewide Planning and Research Cooperative System (SPARCS) database, containing the records of all discharge diagnoses for patients admitted to state-regulated hospitals.

RESULTS

After adjustment for age and race, the hospitalization rate for stroke in zip codes with POPs-contaminated sites was 15% higher than in zip codes without any documented hazardous waste sites (RR 1.15, 95% CI, 1.05, 1.26). For ischemic stroke only, the RR was 1.17 (95% CI 1.04, 1.31). Residents of zip codes containing other waste sites showed a RR of 1.13 (95% CI, 1.02, 1.24) as compared to zip codes without an identified waste site.

CONCLUSION

These results suggest that living near a source of POPs contamination constitutes a risk of exposure and an increased risk of acquiring cerebrovascular disease. However further research with better control of individual risk factors and direct measurement of exposure is necessary for providing additional support for this hypothesis.

Cigarette smoking among spouses: another risk factor for stroke in women

BACKGROUND AND PURPOSE

It is well known that passive exposure to cigarette smoking increases the risk of coronary events, but the effect on the risk of stroke is not well defined. We performed this study to determine the effect of cigarette smoking among spouses on the risk of developing stroke and ischemic stroke among a nationally representative sample of women.

METHODS

We examined the association between history of smoking among spouses with the incidence of stroke in a national cohort of 5379 women who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-Up Study.

RESULTS

During a mean follow-up of 8.5 years, the risk was significantly increased for all strokes (relative risk, 5.7; 95% CI, 1.4 to 24) and ischemic stroke (relative risk, 4.8; 95% CI, 1.2 to 20) among cigarette-smoking women with a cigarette-smoking spouse compared with those with a nonsmoking spouse after adjusting for other cardiovascular risk factors.

CONCLUSIONS

The study provides new evidence linking spousal smoking to stroke.

Inmate exposure to secondhand smoke in correctional facilities and the impact of smoking restrictions

This study was undertaken to measure the passive smoking exposure of prisoners at three correctional facilities in the US and to evaluate the effectiveness of a ban on smoking in reducing these exposures at two of these facilities. The average weekly concentration of nicotine was measured in fixed locations within the correctional facilities using passive samplers. Samples were collected before and after a smoking ban was instituted, and after the policy was modified to allow smoking outdoors. Samples were collected in the living areas, near where inmates slept and watched TV, and in selected central facilities, including dining halls, visiting rooms, booking areas, and learning centers. Average weekly concentrations of nicotine were measured in 84 locations while smoking was allowed; changes in these concentrations were measured with 112 weekly samples 4 and 9 months after the policy restricting smoking was implemented The average concentrations of nicotine were high while smoking was allowed: most living and sleeping areas averaged 3-11 microg/m(3), but the gym that was used as a bunkroom averaged 25 microg/m(3); these values compare to an average of 2 microg/m(3) in the homes of smokers. The smoking ban significantly reduced nicotine concentrations in the living areas (P<0.01 at facility A and P<0.05 at facility B) to averages of 1.5-2.2 microg/m(3); all postban samples were less than 5 microg/m(3). In conclusion, secondhand smoke concentrations in correctional facilities can be quite high; however, policies banning smoking are effective in reducing, but not eliminating, these exposures.

Estimate of deaths attributable to passive smoking among UK adults: database analysis

OBJECTIVE

To estimate deaths from passive smoking in employees of the hospitality industry as well as in the general workforce and general population of the United Kingdom.

DESIGN

Calculation, using the formula for population attributable proportion, of deaths likely to have been caused by passive smoking at home and at work in the UK according to occupation. Sensitivity analyses to examine impact of varying assumptions regarding prevalence and risks of exposure.

SETTING

National UK databases of causes of death, employment, structure of households, and prevalences of active and passive smoking.

MAIN OUTCOME MEASURES

Estimates of deaths due to passive smoking according to age group (< 65 or > or = 65) and site of exposure (domestic or workplace).

RESULTS

Across the United Kingdom as a whole, passive smoking at work is likely to be responsible for the deaths of more than two employed people per working day (617 deaths per year), including 54 deaths in the hospitality industry each year. Each year passive smoking at home might account for another 2700 deaths in persons aged 20-64 years and 8000 deaths among people aged > or = 65.

CONCLUSION

Exposure at work might contribute up to one fifth of all deaths from passive smoking in the general population aged 20-64 years, and up to half of such deaths among employees of the hospitality industry. Adoption of smoke free policies in all workplaces and reductions in the general prevalence of active smoking would lead to substantial reductions in these avoidable deaths.

Respiratory health consequences of environmental tobacco smoke

Over the last several decades there has been a growing interest in examining the health consequences of environmental tobacco smoke (ETS). As a result of a wide body of research, ETS is now considered an unacceptable and entirely preventable public health hazard, and public policy increasingly discourages the presence of tobacco smoke in the public domain. This article provides an overview of the composition of ETS and the major diseases and disorders strongly linked to ETS, emphasizing the effects of ETS on pulmonary function, asthma, and lung cancer.

Are multiple acute small subcortical infarctions caused by embolic mechanisms?

OBJECTIVE

To seek evidence of potential embolic sources or other stroke mechanisms in patients who, on chance observation, had several apparently recent small subcortical infarcts on diffusion weighted magnetic resonance imaging (DWI).

METHODS

Patients presenting with stroke and multiple hyperintense subcortical infarcts visible on DWI were identified prospectively. Detailed clinical and radiological assessments were done independently and blinded to each other.

RESULTS

Of 10 patients with multiple hyperintense subcortical infarcts on DWI, a definite embolic source was identified in only one. Most patients were hypertensive and smoked. The DWI appearance suggested that the subcortical lesions had occurred within several weeks rather than at exactly the same time. Most patients also had significant white matter hyperintensities and four had microhaemorrhages.

CONCLUSIONS

Embolic sources were not identified in most patients but they did have systemic vascular risk factors and brain imaging features of "small vessel disease." A more generalised intrinsic process affecting many small cerebral vessels contemporaneously could explain multiple acute small subcortical infarcts. White matter hyperintensities, microhaemorrhages, and multiple small subcortical infarcts may share a common pathophysiological mechanism such as a diffuse cerebral microvascular abnormality which requires further exploration.

Secondary prevention strategies in ischemic stroke: identification and optimal management of modifiable risk factors

The identification and treatment of modifiable Ischemic stroke risk factors, in addition to appropriate antithrombotic therapy, can reduce the likelihood of first or recurrent stroke, prevent long-term morbidity and mortality after first stroke or transient Ischemic attack, and lower health care costs. Long-term morbidity and mortality in patients with ischemic stroke includes patients with coronary artery disease. Therefore, in patients with ischemic stroke (especially those with carotid artery disease and lacunar disease), the goal is to prevent not only recurrent stroke but also coronary artery disease. Neurologists and general practitioners must be aware of the specific risk factors and recommendations for patients with ischemic stroke and apply the information systematically. We review known risk factors for ischemic stroke and current recommendations for treatment, focusing primarily on atherosclerotic risk factors as they apply to patients with stroke. In particular, recent data on hypertension and hyperlipidemia are described. In addition, we discuss the challenges in managing these risk factors and the potential strategies for overcoming them.

Passive smoking and risk of coronary heart disease and stroke: prospective study with cotinine measurement

OBJECTIVE

To examine the associations between a biomarker of overall passive exposure to tobacco smoke (serum cotinine concentration) and risk of coronary heart disease and stroke.

DESIGN

Prospective population based study in general practice (the British regional heart study).

PARTICIPANTS

4729 men in 18 towns who provided baseline blood samples (for cotinine assay) and a detailed smoking history in 1978-80.

MAIN OUTCOME MEASURE

Major coronary heart disease and stroke events (fatal and non-fatal) during 20 years of follow up.

RESULTS

2105 men who said they did not smoke and who had cotinine concentrations < 14.1 ng/ml were divided into four equal sized groups on the basis of cotinine concentrations. Relative hazards (95% confidence intervals) for coronary heart disease in the second (0.8-1.4 ng/ml), third (1.5-2.7 ng/ml), and fourth (2.8-14.0 ng/ml) quarters of cotinine concentration compared with the first (> or = 0.7 ng/ml) were 1.45 (1.01 to 2.08), 1.49 (1.03 to 2.14), and 1.57 (1.08 to 2.28), respectively, after adjustment for established risk factors for coronary heart disease. Hazard ratios (for cotinine 0.8-14.0 nu > or = 0.7 ng/ml) were particularly increased during the first (3.73, 1.32 to 10.58) and second five year follow up periods (1.95, 1.09 to 3.48) compared with later periods. There was no consistent association between cotinine concentration and risk of stroke.

CONCLUSION

Studies based on reports of smoking in a partner alone seem to underestimate the risks of exposure to passive smoking. Further prospective studies relating biomarkers of passive smoking to risk of coronary heart disease are needed.

Cardiovascular health and economic effects of smoke-free workplaces

PURPOSE

Smoking is the leading controllable risk factor for heart disease. Only about 69% of U.S. indoor workers are currently covered by a smoke-free workplace policy. This analysis projects the cardiovascular health and economic effects of making all U.S. workplaces smoke free after 1 year and at steady state.

METHODS

We estimated the number of U.S. indoor workers not covered by smoke-free workplace policies, and the effects of making all workplaces smoke free on smoking behavior and on the relative risks of acute myocardial infarctions and strokes. One-year and steady-state results were calculated using an exponential decline model. A Monte Carlo simulation was performed for a sensitivity analysis.

RESULTS

The first-year effect of making all workplaces smoke free would produce about 1.3 million new quitters and prevent over 950 million cigarette packs from being smoked annually, worth about 2.3 billion dollars in pretax sales to the tobacco industry. In 1 year, making all workplaces smoke free would prevent about 1500 myocardial infarctions and 350 strokes, and result in nearly $60 [corrected] in savings in direct medical costs. At steady state, 6250 myocardial infarctions and 1270 strokes would be prevented, and $279 million [corrected] would be saved in direct medical costs annually. Reductions in passive smoking would account for 60% of effects among acute myocardial infarctions.

CONCLUSION

Making all U.S. workplaces smoke free would result in considerable health and economic benefits within 1 year. Reductions in passive smoking would account for a majority of these savings. Similar effects would occur with enactment of state or local smoke-free policies.

Smoking as a crucial independent determinant of stroke

Background

Although smoking is known to be powerful risk factor for other vascular diseases, such as cardiac and peripheral vascular disease, only relatively recently has evidence for the role of smoking in the development of stroke been established. The reasons for this advance lie in the acknowledgement that stroke is a heterogeneous disease, in which its subtypes are associated with different risk factors. Furthermore, improvements in the stringency of epidemiological studies and the greater use of CT scanning have enabled the role of smoking in the development of stroke to be elucidated.

Summary of review

This is a qualitative examination of high quality epidemiological studies in which the role of smoking and passive smoking, as a risk factor for cerebral infarction, intracerebral haemorrhage and subarachnoid haemorrhage, is examined. In addition, the pathological mechanisms by which smoking or passive smoking may contribute to the development of stroke are reviewed.

Conclusion

Smoking is a crucial independent determinant of cerebral infarction and subarachnoid haemorrhage, however its role in intracerebral haemorrhage is unclear. Although studies are limited, there is evidence that exposure to passive smoking may also increase the risk of stroke. Smoking appears to be involved in the pathogenesis of stroke via direct injury to the vasculature and also by altering haemodynamic factors within the circulation. Importantly, smoking is modifiable risk factor for stroke. Therefore, the encouragement of smoking cessation may result in a substantial reduction in the incidence of this devastating disease.

Air Pollution and Cardiovascular Disease

Air pollution is a heterogeneous, complex mixture of gases, liquids, and particulate matter. Epidemiological studies have demonstrated a consistent increased risk for cardiovascular events in relation to both short- and long-term exposure to present-day concentrations of ambient particulate matter. Several plausible mechanistic pathways have been described, including enhanced coagulation/thrombosis, a propensity for arrhythmias, acute arterial vasoconstriction, systemic inflammatory responses, and the chronic promotion of atherosclerosis. The purpose of this statement is to provide healthcare professionals and regulatory agencies with a comprehensive review of the literature on air pollution and cardiovascular disease. In addition, the implications of these findings in relation to public health and regulatory policies are addressed. Practical recommendations for healthcare providers and their patients are outlined. In the final section, suggestions for future research are made to address a number of remaining scientific questions.

The measurement of exhaled carbon monoxide in healthy smokers and non-smokers

The measurement of exhaled carbon monoxide (CO) level may provide an immediate, non-invasive method of assessing smoking status. The aims of this study were to use a portable CO monitor to compare the exhaled CO levels in established smokers and non-smokers. The exhaled CO levels were measured in 322 subjects (243 healthy smokers, 55 healthy non-smokers, 24 passive smokers) who applied to healthy stand during the spring student activity of Firat University in Elaziğ. Exhaled CO concentration was measured using the EC50 Smokerlyser. The mean exhaled CO level was 17.13+/-8.50 parts per million (ppm) for healthy smokers and 3.61+/-2.15 ppm for healthy non-smokers, and 5.20+/-3.38 ppm for passive smokers. There were significant positive correlation between CO levels and daily cigarette consumption, and CO levels and duration of smoking in healthy smokers (r=+0.550, P<0.001, r=+0.265, P<0.001, respectively. Spearman's test). When smokers and non-smokers were looked at as a whole, a cutoff of 6.5 ppm had a sensitivity of 90% and specificity of 83%. In conclusion, exhaled CO level provides an easy, an immediate way of assessing a subject's smoking status.