Active cigarette smoking represents the single most important preventable cause of death in the United States, accounting for over 400 000 deaths from cancer, cardiovascular disease, and chronic lung disease. Until the mid 1980s, cigarette smoking was considered a matter of personal choice and individual rights. However, publication of the 1986 Surgeon General's Report on the Health Effects of Involuntary Smoking,11 which clearly documented that exposure to environmental tobacco smoke (ETS) causes lung cancer in nonsmokers, spawned a rapid public health response. Today, the ban on smoking in offices, airplanes, public buildings, and restaurants is seen by many as an appropriate response to preservation of public health. This represents an evolution in the attitudes of the American public since the television advertising ban was instated after the landmark 1964 Surgeon General's Report on active smoking.
The 1986 Surgeon General's Report devoted only 2 of its 359 pages to adverse cardiovascular health outcomes related to environmental tobacco smoke. Since 1984, there have been at least 15 publications (including Steenland et al2 in this issue of Circulation) that have demonstrated that ETS affects lipid levels, angina, and myocardial infarction. These adverse health effects may be due to a myriad of biochemical mechanisms of tobacco smoke exposure, including greater platelet aggregation, endothelial cell damage, reduced oxygen supply, greater oxygen demand, and the direct effects of nicotine and carbon monoxide. Meta-analyses of these data and the current report by Steenland et al indicate a 20% increase in coronary disease mortality secondary to ETS exposure of spouses of smokers. Although the absolute increase in risk is small, the total number of individuals with coronary disease is large: over 200 000 deaths per year occur from myocardial infarction. An estimated 35 000 to 40 000 individuals die each year of myocardial infarction as a result of ETS exposure. Lung cancer linked to ETS causes only 3000 to 4000 deaths per year; thus, the cardiovascular mortality effects are 10-fold greater.
One triumph of ETS research has been our ability to precisely quantify and identify a low-risk exposure, to measure precisely its public health impact, and to move effectively to implement changes in public policy to protect public health. More remains to be done. Thirty percent of adult Americans continue to smoke, and >50% of children are estimated to be exposed to ETS during the course of their daily lives. Clearly, more research needs to be done, both to better quantify risk and to understand the mechanisms of exposure and their relationship to disease. Public policy should continue to apply these emerging scientific results to increase education and promote exposure reduction among the public.
Physicians can help. The adverse health effects of tobacco have been debated for at least 400 years and have been aggressively countered by the industry and its paid consultants. As informed physicians, we have a public responsibility to speak out on America's number one preventable cause of death. In recognition of the major influence of ETS as a public health problem, the American Heart Association issued a position statement in 1992 detailing the adverse cardiovascular health effects of ETS. It is worth quoting from the last sentence of that position paper, which reads, “A smoke-free environment in the home, public buildings, and workplace should be the goal of society.”3 We as physicians should work for nothing less.
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
- Copyright © 1996 by American Heart Association
US Department of Health and Human Services. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General Office on Smoking and Health. Rockville, Md: 1986.
Steenland K, Thun M, Lally C, Heath C Jr. Environmental tobacco smoke and coronary heart disease in the American Cancer Society CPS-II cohort. Circulation.. 1996;94:622-628.
Taylor AE, Johnson DC, Kazemi H. Environmental tobacco smoke and cardiovascular disease. Circulation.. 1992;86:1-4.