Nephrology Dialysis Transplantation

NDT Advance Access originally published online on February 17, 2007
Nephrology Dialysis Transplantation 2007 22(6):1508-1511; doi:10.1093/ndt/gfm046

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Second-hand smoke—a license to kill due to expire

Krzysztof Narkiewicz

Department of Hypertension and Diabetology, Medical University of Gdask, Gdask, Poland

Correspondence and offprint requests to: Krzysztof Narkiewicz, MD, PhD, Department of Hypertension and Diabetology, Medical University of Gdask, Debinki 7c, 80-952 Gdask, Poland. Email: knark{at}amg.gda.pl

Keywords: atherosclerosis; cardiovascular disease; epidemiology; passive smoking; second-hand smoke; smoking

James Bond: What do you expect from me, to talk?

A. Goldfinger: No Mr Bond, I expect you to die!

‘Goldfinger’ movie

There is growing evidence that second-hand smoke is not only harmful, but also in all probability, fatal to those exposed to it [1–3]. Most smokers object to the charge that they are endangering others, and many would be offended by the notion that they, like the character Auric Goldfinger, have a conscious intention to kill others. But tell that to those who must inhale their smoke and you will hear many respond, ‘What do you expect from us, to breathe your poison?’.

By now, most people in the non-medical community are aware of the debate concerning second-hand smoke from tobacco, or have at least heard some of the arguments both pros and cons. Phrases like ‘smokers’ rights’ and ‘non-smokers’ protections’ often cloud the discussion, as one side or the other gets hung up on the civil rights aspects of it all. In addition, the tobacco industry has attempted to challenge the focus and dialogue related to the epidemiological evidence on passive smoking [4]. The result of this uproar has been endless bickering with no resolution of the case. Therefore, in order to clear the air of all emotion, we need only to look purely and calmly at the scientific research concerning second-hand smoke. The evidence, which already speaks for itself, overwhelmingly favours smoke-free policies, in both public premises and private workplaces.

	Epidemiology

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
Clear and present danger
A significant number of non-smokers (up to 85% in some European countries) are passively exposed to tobacco smoke at home or at work [5]. In 2002, no country in Europe enforced smoke-free policies in pubs, bars or nightclubs and virtually all visitors and employees in those settings were exposed to second-hand smoke. Furthermore, it should be noted that most current ventilation systems do not protect against exposure to tobacco smoke [6]. In comparison with active smoking (Table 1), the magnitude of the reported risks associated with passive smoking is relatively modest (Table 2) [5]. However, because a large number of non-smokers are exposed to second-hand smoke in workplaces and enclosed public places, the potential harm caused by passive smoking is striking. Passive smoking currently kills 79 000 European Union (EU) citizens a year [5]. More than 50 000 deaths annually in the US from ischaemic heart disease are associated with second-hand smoke [7].

View this table: [in this window] [in a new window]   Table 1. Relative risks associated with active smoking [5]

 

View this table: [in this window] [in a new window]   Table 2. Relative risks associated with passive smoking [5]

 

	Why is this relevant to the nephrologist?

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
The renal connection
Today, every nephrologist is well aware of the risk of active smoking. Fewer, however, are alert to the potential risk of second-hand smoke. Smoking increases the risk of progression in renal disease [8], in both diabetic and non-diabetic patients, and may increase serum creatinine concentrations, even in patients without primary renal disease [9,10]. In a large population based study of 23 523 individuals, Haroun et al. [11] found that almost one-third of the attributable risk of chronic kidney disease was associated with cigarette smoking. Endothelial cell dysfunction has been suggested as one of the major underlying pathomechanisms [12,13] and this hypothesis is supported by the anatomical finding of more severe vascular lesions in the kidneys of smokers with primary renal disease [14]. Smokers have more frequently elevated albumin excretion rate [15,16] and overt proteinuria [17]. Against this background, passive smoking should be a cause for concern; indeed, passive smoking has recently been shown to increase albumin excretion [18].

	Cardiovascular effects of second-hand smoke

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
A view to a kill
The impact of passive smoking on the cardiovascular system was already recognized 20 years ago. The evidence that second-hand smoke increases cardiovascular risk has continued to accumulate in terms of both the epidemiological findings and a better understanding of mechanisms [19]. Reviews of recent literature clearly indicate that passive smoke has much larger effects on the cardiovascular system than would be expected, taken from a comparison of smoke exposure in active and passive smokers [1,2]. Although the same has not yet been directly documented in patients with chronic kidney disease, such a scenario is extremely likely in view of the above arguments. While the dose of smoke delivered to passive smokers is approximately 100 times smaller than that delivered to an active smoker, the effects of even brief (minutes to hours) passive smoking are often nearly as large (averaging 80–90%) as chronic active smoking [1].

The effects of second-hand smoke on the cardiovascular system are both direct and indirect [1,20]. The mechanisms by which passive smoking may lead to cardiovascular events include platelet activation, endothelial dysfunction, inflammation, increased oxidative stress, decreased energy metabolism, impaired autonomic function, and increased arterial stiffness (Figure 1). Even 30 min of passive smoking rapidly impairs vascular endothelial function, and increases oxidative stress [21,22]. In both children and adults, passive smoking leads to lower levels of high-density lipoprotein cholesterol which per se might accelerate the development of atherosclerosis [23,24]. Second-hand smoke also contributes to atherosclerotic plaque instability, which might trigger acute cardiovascular events [1].

View larger version (14K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 1. Potential mechanisms linking passive smoking to cardiovascular disease.

 
Furthermore, second-hand smoke might lead to cardiovascular disease by increasing insulin resistance [25]. In comparison with non-smokers not exposed to second-hand smoke, passive smokers are more likely to develop clinically relevant glucose intolerance or diabetes [26].

Finally, second-hand smoke might also be operative in increasing cardiovascular risk by accelerating renal dysfunction. Indeed, passive smoking has been associated with higher albumin excretion and higher von Willebrand factor activity [18].

	Economical benefits of smoke-free policies

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
Chain reaction
Putting all the medical arguments aside for a moment, one should look at the economic and social benefits of smoke-free policies in public areas and private workplaces to get a more complete picture. As more and more studies are conducted on this issue, it becomes clear that non-smoking ordinances promote a reduction in cigarette consumption of smokers [27], and better yet, a decrease in both the initiation and prevalence of smoking among young people [27]. The impact of smoke free-policies is greater as these measures become more restrictive and comprehensive.

For those who are bottom-line when it comes to deciding for or against a public policy, there are countless statistics demonstrating the potential economic benefits of smoke-free rules and laws [27]. These include increased productivity among those who quit smoking and among workers no longer exposed to second-hand smoke; lower hiring costs due to a reduced need to replace labour lost; savings due to reduced employers’ liabilities for the impact of second-hand smoke exposure, and reduced insurance costs [27]. All of these factors might enhance many countries’ human capital, leading to economic growth.

	Smoke-free policies

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
Mission possible
Over the last decade, public awareness of the harmful effects of second-hand smoke resulted in increased support for measures to protect non-smokers from second-hand smoke. Someone had to be brave enough to get the ball rolling on enforcing smoke-free policies, and roll it they did.

On 29 March 2004, Ireland became the first country in Europe to implement a comprehensive ban on smoking at the workplace, including bars and restaurants. Subsequently, smoke-free policies were introduced in Norway, Italy, Malta, Sweden and Scotland. Several other European nations plan to implement similar legislation in the near future.

Smoke-free workplace legislation enjoys a high level of public support (Figure 2). Furthermore, this support increases after its implementation (Figure 2), and is not limited to non-smokers [28]. For example, the approval among Irish smokers increased from 6 to 48% [28]. Studies evaluating the financial impact of smoke-free policies show that a smoking ban in bars and restaurants has no negative long-term impact on business [29]. On the other hand, smoke-free policies lead to significant reductions in smoking prevalence and average cigarette consumption among continuing smokers. For example, in Italy, a 9% drop in cigarette sales was observed after the introduction of smoke-free laws [30].

View larger version (38K): [in this window] [in a new window] [Download PowerPoint slide]   Fig. 2. Support for free smoke-free law (before and after its implementation) and compliance with the legislation in various locations [28].

 

	Medical benefits of going smoke-free

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
Die another day
The California Tobacco Control Program endorsing smoke-free policies has been associated with preventing 59 000 cardiovascular deaths between 1989 and 1997 [31]. The number of acute myocardial infarction admissions decreased after the implementation of a smoking ban in public areas and private workplaces in a geographically isolated community in the US (Helena, Montana) [32]. This effect was partially reversed when enforcement of the law was suspended by a lawsuit [32]. Barone-Adesi et al. [33] have recently shown that national laws banning smoking in public places resulted in a significant reduction in hospital admissions for acute myocardial infarction in a population of four million inhabitants of the Piedmont region (northern Italy).

	Conclusions

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 
Taken together, the medical, social and economic benefits of smoke-free policies, both public and private, can be observed and substantiated by the people of Ireland and several other countries who have gained personally and together to become healthier societies. The tide is turning, through the support of Europe's various medical authorities and health ministers, towards more and more smoke-free workplace legislations. As the Swedish Minister of Health, Morgan Johansson, said at the Luxembourg Smoke-free Europe conference on 2 June 2005: "In five years time there will be a majority of the European Union countries with smoke-free laws, and in another five years, it will be the exception to the rule NOT to be smoke-free." Let's hope so.

Conflict of interest statement. None declared.

	References

Top Epidemiology Why is this relevant... Cardiovascular effects of second... Economical benefits of smoke... Smoke-free policies Medical benefits of going... Conclusions References

 

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Received for publication: 22.12.06
Accepted in revised form: 16. 1.07

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