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September, 2008:

Smoking Parents Can Hook Kids On Nicotine

Charlie Fidelman – Canwest News Service – Tuesday, September 30, 2008

You know smoking sets a bad example for the kids and second-hand smoke is harmful. As if that wasn’t warning enough, a strongly worded Montreal study shows someone else’s smoke can lead to nicotine addiction in children.

“Increased exposure to second-hand smoke, both in cars and homes, was associated with an increased likelihood of children reporting nicotine dependence symptoms — even though these kids had never put a cigarette in their mouths,” said epidemiologist Jennifer O’Loughlin, senior author of the study and a professor at the Universite de Montreal.

Published in the September edition of the journal Addictive Behaviors, the study, involving nine Canadian institutions, builds on previous findings on second-hand smoke in non-smokers and withdrawal symptoms including depression, anxiety and trouble concentrating.

The physiological consequences of second-hand smoke have already been shown, O’Loughlin said of bar and restaurant workers (before the cigarette ban) with nicotine metabolites in their urine and saliva as if they had smoked.

Also, it is known that children exposed to second-hand smoke started smoking earlier than other children, said O’Loughlin who, in a previous study, mapped the stepping stones to tobacco addiction, showing it can take one puff to turn a teenager into a smoker.

The study looked at students age 10 and 11 from 29 Montreal area schools. It found an association between exposure to second-hand smoke and nicotine dependence.

Five per cent of 1,488 children who never smoked but were exposed to second-hand smoke reported symptoms of nicotine addiction.

“They told us, ‘I want it, I need it,’ and that they are physically and mentally addicted,” O’Loughlin said. “Why would a kid do that?”

Lead investigator Mathieu Belanger said he was surprised to see evidence of nicotine dependence in children as young as 10, even though they had never smoked.

“But we were not surprised to see it was related to second-hand smoke,” said Belanger, research director of the Centre de Formation Medicale du Nouveau Brunswick.

Researchers did not make a direct link between cause and effect, Belanger said.

“More studies are needed. But there’s a lesson for parents,” he added.

“Most (of those reporting nicotine dependence) came from homes of smokers,” Belanger said, or they had friends that already smoked. “Maybe there’s a genetic path we’re not yet exploring.”

While it may seem unconventional that non-smokers are reporting cigarette cravings, Belanger also noted tobacco studies have found toddlers with carcinogens in their blood related to second-hand smoke.

The next step will focus on following these children to see whether they pick up smoking faster than others, he said.

The study was funded by the Canadian Tobacco Control Research Initiative, the Institut national de sante publique du Quebec and the Canadian Institutes of Health Research.

Committee Recommends Ban On Tobacco Displays [New Zealand]

Stuff | Monday, 29 September 2008

A Parliamentary committee says the Government should ban tobacco and cigarette displays in shops. The Health Committee made the recommendation after considering a petition signed by more than 20,000 people in support of the ban.

The National Party, in a minority view, said there needed to be more evidence before implementing a ban. There was already a ban on advertising tobacco products but they could still be displayed in shops. The Health Ministry said there were over 10,000 retail outlets selling tobacco products, usually displayed in large highly visible units.

The New Zealand Association of Convenience Stores said tobacco products accounted for about 37 percent of members’ annual sales. The association said financial incentives offered to retailers by tobacco companies were confidential.

The ministry is looking at whether such arrangements are allowed, under smokefree legislation. The association said moving displays units would cost each retailer up to $6000 and revenue would decline. It also said risk to retailers would be heightened if staff had to take their eyes off customers to get cigarettes from under counters.

The report said in other countries where bans were implemented stores had not had to close, nor were jobs lost. The committee recommended shop interiors be made visible to the street to improve safety.

Iceland, Thailand and most of Canada banned displays. Iceland recorded some decline in smoking but it could not be attributed solely to the ban.

In New Zealand, smoking decreased by 23.4 percent in 2002-03 to 18.87 percent in 2006-07.

The Health Ministry estimated the cost of smoking to the economy at $1.7 billion as of 2005. Smoking caused illnesses cost the health system between $300 million and $350 million a year.

Action on Smoking and Health (ASH) New Zealand welcomed the committee’s decision. ASH director Ben Youdan said tobacco should not be treated like other products. “It kills half the people who use it, yet for too long we have allowed these addictive and deadly poisons to be sold next to the milk and chocolates.

Mr Youdan said the ban was critical to tackling youth smoking. The average start age was around 14-15 years old. “Young people are the new recruits the tobacco companies need to replace the 4700 Kiwis who die every year from smoking.”

“We know this ban will be effective — that’s why industry has been so vocally opposed to the idea — the displays are one of the last bastions of cigarette marketing.”

During submissions researchers said the displays were de facto advertising which encouraged impulse buys and made it harder for people trying to kick the habit

Light vs Regular Cigarettes on Nicotine

26-Sep-2008 – University of California – Los Angeles

Do ‘light’ cigarettes deliver less nicotine to the brain than regular cigarettes?

For decades now, cigarette makers have marketed so-called light cigarettes — which contain less nicotine than regular smokes — with the implication that they are less harmful to smokers’ health. A new UCLA study shows, however, that they deliver nearly as much nicotine to the brain.

Reporting in the current online edition of the International Journal of Neuropsychopharmacology, UCLA psychiatry professor Dr. Arthur L. Brody and colleagues found that low-nicotine cigarettes act similarly to regular cigarettes, occupying a significant percentage of the brain’s nicotine receptors.

Light cigarettes have nicotine levels of 0.6 to 1 milligrams, while regular cigarettes contain between 1.2 and 1.4 milligrams.

The researchers also looked at de-nicotinized cigarettes, which contain only a trace amount of nicotine (0.05 milligrams) and are currently being tested as an adjunct to standard smoking-cessation treatments. They found that even that low a nicotine level is enough to occupy a sizeable percentage of receptors.

“The two take-home messages are that very little nicotine is needed to occupy a substantial portion of brain nicotine receptors,” Brody said, “and cigarettes with less nicotine than regular cigarettes, such as ‘light’ cigarettes, still occupy most brain nicotine receptors. Thus, low-nicotine cigarettes function almost the same as regular cigarettes in terms of brain nicotine-receptor occupancy.

“It also showed us that de-nicotinized cigarettes still deliver a considerable amount of nicotine to the brain. Researchers, clinicians and smokers themselves should consider that fact when trying to quit.”

In the brain, nicotine binds to specific molecules on nerve cells called nicotinic acetylcholine receptors, or nAChRs. When nerve cells communicate, nerve impulses jump chemically across gaps between cells called synapses by means of neurotransmitters. The neurotransmitters then bind to the receptor sites on nerve cells — in the case acetylcholine resulting in the release of a pleasure-inducing chemical called dopamine. Nicotine mimics acetylcholine, but it lasts longer, releasing more dopamine.

“It can cause specific neurons to communicate and thus increases dopamine for an extended period of time,” Brody said. “Most scientists believe that’s one key reason why nicotine is so addictive.”

In an earlier study, researchers determined that smoking a regular, non-light cigarette resulted in the occupancy of 88 percent of these nicotine receptors. However, that study did not determine whether inhaling nicotine or any of the thousands of other chemical found in cigarette smoke resulted in this receptor occupancy. The central goal of the present study was to determine if factors associated with smoking — other than nicotine — resulted in nAChR occupancy.

The authors reasoned that if nicotine is solely responsible for receptor occupancy, then smoking a de-nicotinized cigarette or a low-nicotine cigarette would result in the occupancy of roughly 23 percent and 78 percent of nicotine receptors, respectively, based on the cigarettes’ nicotine content.

“That would still be substantial,” Brody said.

Fifteen smokers participated in the study. Each was given positron emission tomography (PET) scans, a brain-imaging technique that uses minute amounts of radiation-emitting substances to tag specific molecules. In this case, the tracer was designed to bind to the nicotine receptors in the brain.

The researchers could then measure what percentage of the tracer was displaced by nicotine when the research subjects smoked. In total, 24 PET scans were taken of participants’ brains before and after three different conditions: not smoking, smoking a de-nicotinized cigarette and smoking a low-nicotine cigarette.

The PET data showed that smoking a de-nicotinized cigarette and a low-nicotine cigarette occupied 26 percent and 79 percent of the receptors, respectively, which was very close to what the researchers had originally estimated.

“Given the consistency of findings between our previous study with regular cigarettes and the present study — that showed us that inhaling nicotine during smoking is solely responsible for occupancy of brain nicotine receptors,” Brody said.

English Pub Sells Electronic Cigarettes To Indoor Smokers

Patrick Horan with wires – Herald Sun – AFP, Reuters | September 26, 2008

AN English pub reckons it has the perfect solution to the smoking ban as their winter approaches – an electronic cigarette.

The UK Telegraph reports that the Butler’s Arms near Birmingham is selling the new E.cig, a device that smokes like a real cigarette with users getting a shot of nicotine every time they inhale.

It even produces a cloud of water vapour with every puff.

Electronic cigarettes are usually made of stainless steel and have a chamber for storing liquid nicotine in various concentrations.

Users puff on them as they would a real cigarette but do not light them – rather the cigarettes produce a fine, heated mist which is absorbed into the lungs.

The makers of the product, The Electronic Cigarette Company, claims the gadgets offer a “new generation of healthier smoking”.

The pub’s assistant manager Becky Giles, 18, told the Telegraph: “It is just like a real cigarette but without all the bad elements.

“There is no harm to other people in the bar as no smoke is given out, just water vapour, and there is no smell like with a real cigarette.”

But despite Becky’s considered opinion, the World Health Organisation isn’t so sure, warning the product could prove highly poisonous because it has not been subjected to rigorous scientific tests.

“It’s 100 per cent false to affirm this is a therapy for smokers to quit,” WHO anti-tobacco official Douglas Bettcher told journalists.

“There are a number of chemical additives in the product which could be very toxic,” he warned.

The WHO “knows of absolutely no scientific evidence whatsoever that would confirm that the electronic cigarette is a safe and effective smoking cessation device,” he added.

The WHO is particularly aggrieved that some manufacturers have implied the organisation views it as a legitimate nicotine replacement therapy, like nicotine gum, lozenges and patches.

“Manufacturers of this electronic cigarette around the world have included WHO’s name or logo, for example on their website, on package inserts or on advertisements,” Bettcher said, without naming any company or manufacturer.

The WHO has sent “cease-and-desist” letters to the manufacturers demanding they immediately withdraw these claims or otherwise face legal action.

First made in China and sold mainly over the internet in countries including Brazil, Britain, Canada and Israel, electronic cigarettes have grown in popularity despite a lack of regulatory approval.

Back at the Butler’s Arms, a starter pack costs £39.99 ($88), and users can choose between No nicotine, Low, medium or high nicotine, menthol, strawberry or cherry.

Where There’s Smoke

Indonesia is a world leader in cigarette consumption, but health advocates face an uphill battle in the face of a powerful tobacco lobby and seemingly indifferent politicians

Fabio Scarpello – SCMP – Updated on Sep 25, 2008
The performance by American singer Alicia Keys in Jakarta in July was notable for more than just the quality of the music. The sultry R&B star took a stance against cigarette advertisements and earned herself more than a few extra fans among Indonesia’s anti-smoking lobby. Her position led to Philip Morris International withdrawing its sponsorship – something quite extraordinary in a country where tobacco advertisements are ubiquitous.

“I am an unyielding advocate for the well-being of children around the world and do not condone or endorse smoking,” Keys said at the time, and the comment could not have been made in a more appropriate place.

Indonesia, the world’s fourth-most populous country, also has one of the world’s youngest populations and it is the incidence of smoking among the young that is most disturbing to the anti-smoking lobby.

According to a World Health Organisation global youth tobacco survey last year, smokers in Indonesia are getting younger, with the number of smokers aged between five and nine climbing dramatically.

The same study said more than 141 million – or over half of Indonesia’s 220 million inhabitants – were smokers and as many as 78.2 per cent of those were youngsters. This percentage has doubled in just three years. Indonesia is third on the list of countries with the largest number of smokers, after China and Russia, but has the highest percentage of juvenile smokers.

Experts say this is due to the fact that producers are targeting young people, while the government and lawmakers do little to prevent it, with legislation limited and rarely enforced.

Rita Damayanti, of the University of Indonesia’s Faculty of Public Health, said that children too young to buy cigarettes were being targeted by the cigarette industry, which wanted to get them addicted and become long-term smokers.

“Even though it is illegal to show a picture of cigarettes, cigarette companies just work twice as hard to send the message,” she said.

Mrs Damayanti explained that creative advertisements exposed young audiences to positive images, exciting lifestyles of youth culture and heroic characters, followed by a cigarette brand. “And we can predict how children will react to that,” she said.

Cigarette companies regularly hold promotions in parks and at concerts and sports venues. The effect of advertisements is that young people receive strong messages suggesting that smoking is cool. A teenager, cited in a 2006 study conducted by Nawi Ng, a public health specialist, summed up prevailing attitudes among his peers, saying: “If I don’t smoke, I’m not a real man.”

Seto Mulyadi, head of Indonesia’s National Commission on Child Protection, said the government must do more to restrict youth smoking.

“Cigarette companies should not be allowed to sponsor school events and give out free cigarettes. This is simply immoral,” he said.

Mr Mulyadi said cigarette companies had intensified these two approaches since a recent regulation banned television advertisements before 9.30pm.

The major cigarette firms deny targeting the young. “In the last 10 years, all international tobacco companies have changed their policy to not focus on juveniles as their consumers,” Niken Rachmad a spokesman for Sampoerna, which is 98 per cent owned by Philip Morris, told The Jakarta Post.

He added that the tobacco industry targeted only young adults above the age of 18, “for example, university students, who can decide for themselves”.

Mr Mulyadi said that part of the problem was that the law prohibiting sales to minors was not policed. Schoolchildren smoked in the street to general indifference, he said. “The government should also ratify the Framework Convention on Tobacco Control (FCTC), which bans cigarette commercials altogether, among other things,” he added.

The FCTC is a global agreement on public health, which the WHO endorsed at a meeting in Geneva in May 2003. Indonesia was involved in drafting the FCTC but, although the framework has since been ratified by 157 countries, Indonesia has not signed it. North Korea is the only other country in Asia not to have done so.

The government’s relaxed attitude is mirrored by that of lawmakers. Parliament is yet to debate the Control of Impacts of Tobacco Products on Health Bill. The draft has been sitting idle for more than two years. Government inertia means there is unlikely to be an increase in the tobacco tax – a key to fighting cigarette addiction, according to experts.

“If you raise the tobacco tax, you make cigarettes more expensive. It means low-income earners will not waste their money on cigarettes, and young people will not find it affordable to buy cigarettes any more. That is the purpose of increasing the tax. The increased revenue can be put towards tobacco control,” Southeast Asia Tobacco Control Alliance representative Mary Assunta told The Jakarta Post.

The government “hasn’t taken the basic steps it needs to take – banning tobacco advertising, increasing tax, putting graphic warnings on cigarette packs and banning smoking in public places”, Ms Assunta said.

The issue of the tax on cigarettes is a delicate one for politicians who are fearful of damaging the tobacco industry. Indeed, they say it needs to be protected.

The global average for tobacco taxes is 70 per cent of the sales price. In Indonesia, the average is 37 per cent, the lowest in Southeast Asia. Indonesian cigarettes are among the cheapest in the world, with a pack of 20 selling for the equivalent of US$1. Indonesia is the world’s fifth-largest cigarette market and the US$8 billion tobacco industry provides jobs for 7 million people and contributes about 10 per cent of government revenue. The industry expects to pay 42 trillion rupiah (HK$35.02 billion) in excise taxes this year, up from 11 trillion rupiah in 2001. This constitutes the fourth-largest state revenue after value-added tax, corporate income tax, and oil and gas tax.

At a recent tobacco conference, Finance Minister Sri Mulyani Indrawati said that Indonesia needed a healthy tobacco industry and that “the economy and job creation are the government’s No1 priority”.

Tobacco producers represent a powerful and influential lobby that not even the Indonesia Ulama Council (MUI), the country’s highest Islamic body, is able to challenge.

When MUI deputy chairman Amidhan recently mentioned that the body was considering an edict forbidding the country’s 200 million Muslims from smoking, Abdum Hafidz Azis, secretary of the Association of Indonesian Tobacco Farmers, attacked him, saying that the tobacco industry provided jobs and “it would be more human if the MUI switched to a regulation supporting smoking”.

The MUI seems to have dropped the idea.

Health experts are adamant that smoking is a ticking time bomb and that Indonesia will pay dearly.

According to the WHO, about a quarter of deaths in Indonesia in 2005 were caused by smoking and 80 per cent of lung and respiratory cancer cases were due to cigarettes. The WHO estimates that 25 per cent of all male deaths in Indonesia will be smoking related within a decade.

The danger is compounded by the kretek, the clove-flavoured cigarette favoured by 90 per cent of Indonesia’s smokers. Kreteks have roughly double the nicotine and tar levels of ordinary cigarettes.

“I understand that the legislators are concerned about certain kinds of flavours that may lure the underage to smoke. But clove is not one of them. Clove has been used for ages as a flavour in cigarettes,” Indonesian Clove Cigarette Producers Association chairman Ismanu Soemiran told The Jakarta Post.

Anti-smoking campaigners also argue that smoking is making impoverished Indonesians even poorer. In a study of Indonesia’s tobacco economy, Sarah Barber, an economist at the University of California, Berkeley, found that among poor families, an average of 11 per cent of household income was devoted to cigarettes compared with 2.1 per cent spent on health and 1.8 per cent on education. Dr Barber added that “what poor people spend on cigarettes is more than double what they spend on meat, fish and eggs”.

Parents who smoke are also a negative role model.

“If a teenager has parents who smoke, it is really hard for him not to follow,” said Fransciskus, the secretary of the Youth Heart Club.

Fransciskus, 19, is among those trying to stop youngsters from smoking. His club, which operates under the Indonesian Healthy Heart Foundation, advocates healthy living and leading by example.

“We organise bike rides, camping and outdoor activities. We also receive and distribute material about healthy living,” he said.

Fransciskus, who only uses one name, added that what Alicia Keys did was very positive. “Her teenage fans may even support her in that campaign,” he said.

Kicking The Habit

BEN FAWKES – The Dominion Post | Thursday, 25 September 2008

Experts say nicotine is as addictive as heroin or crack cocaine, with most smokers taking close to 20 attempts to stub out the habit.

So when I was offered the chance to try the bioresonance stop smoking treatment – with a reported success rate of between 85 and 90 per cent after one month – I fell upon the opportunity with a mix of hope and disbelief.

Two weeks later, I was standing outside a health shop in Cuba St, smoking my “last” cigarette in preparation for a dose of bioresonance.

It would be my eighth attempt to quit.

The last big effort was in January last year, the result of a rather rash New Year resolution. Three days later, a flatmate found me and a friend going through the rubbish bin to retrieve a rather soggy pack of Marlboro Lights, enthusiastically discarded some time on the morning of January 1.

Undeterred, I made a further attempt six or seven weeks later. My undoing was the rural sports day I had to cover for the country paper I was working on at the time. Having dramatically tossed half a packet of fags out the car window on the way to the sports day, three hours of sheep shearing and dog trials got the better of me, and I spent half an hour on the return trip scrambling around a ditch looking for my discarded Special Filters.

So it was with some trepidation, 18 months later, that I lay plugged in to a machine at The Stop Smoking Clinic, one of two bioresonance providers in Wellington.

The clinic is run by Shona Ellis, a Southlander who worked as a radiographer before becoming interested in bioresonance after meeting a doctor who had it used on patients with allergy problems.

According to Ms Ellis, the advantage of bioresonance is that it not only rids the body of nicotine but also cancels out the craving to smoke.

“Bioresonance is designed to eliminate the cravings to a point where people don’t need to smoke,” she says.

The oldest person Ms Ellis has treated is an 81-year-old and she says it’s not uncommon to have clients who have previously smoked 40 cigarettes a day.

The most important criteria for successful treatment is a motivation to quit, she says.

“If the person is not committed and not serious about it, they’ll just keep smoking and not stop.”


I was determined to give it a crack, but my track record wasn’t so hot.

The treatment was quite straight forward. A probe was stuck into the soles of my feet to take a nicotine reading and I was plugged into the bioresonance machine.

Electrodes were placed on my forehead and chest.

The session lasted about an hour. To finish, I received acupuncture to pressure points in my ears and was dispatched with a potion designed to ease any cravings and an unusual metal disc which apparently carried a memory of my treatment and was to be worn for the next month.

Despite the helpsheet noting that some people had no urge to smoke after the first treatments session, I was not one of them.

The strong cravings I experienced in the first two or three days, progressed to extreme grumpiness and shortness of temper within a week.

But the foul mood eventually passed, and, to my extreme surprise, I didn’t have a single cigarette during the first month.

Another month on, I have smoked – on occasion – but I wouldn’t say I have started smoking again.

It’s more a case of having slipped up a few times, usually under the influence of a few drinks.

Bioresonance has its detractors, among them ASH – the country’s largest antismoking lobby group.

Director Ben Youdan says ASH doesn’t recommend bioresonance due to a lack of clinical evidence and the comparatively high cost when compared with other methods, such as government-subsidised nicotine replacement therapy.

At $395, it is not a cheap, though people who start smoking again inside the first month can opt to have a second treatment at no extra cost.

But nicotine patches – without the government subsidy – are not significantly cheaper.

A 12-week course of patches costs about $315 (based on the cost of a packet of seven patches from the local supermarket).

If subsidised, the same course of treatment costs less than $50.

And though Mr Youdan says nicotine replacement therapy is three to four times more effective than stopping cold turkey, the success rate is still not that high. Given that going cold turkey succeeds with only about three or four per cent of smokers, that puts the success of patches and gum at about 15 per cent.

“Because of the high level of [cigarettes’] addictiveness, it can be really tough to resist,” Mr Youdan says.

“It’s really important that you want to quit.”

How does bioresonance work?

* Bioresonance is said to work through the use of electromagnetic waves.

* It’s believed nicotine emits an electromagnetic charge over your body causing the craving to smoke.

* The machine then reads the energy pattern of the nicotine in the cigarette smoked prior to treatment.

* The opposing wave forms cancel each other out, reducing the electromagnetic charge of nicotine in the body, enabling it to be easily eliminated and dramatically reduce the cravings.

Commission Issues Warning

25 Sep 2008.

New Zealand’s Commerce Commission has issued warnings to three major tobacco companies that the use of the terms ‘light’ and ‘mild’ risked breaching the Fair Trading Act.

The Commerce Commission has been investigating whether the use of the descriptors ‘light’ and ‘mild’ on cigarettes could be potentially misleading under the Fair Trading Act.

“Our concern with these descriptors is that consumers may believe they are exposing themselves to less harm if they smoke these cigarettes, as compared to regular-strength cigarettes,” says Adrian Sparrow, director of the Commerce Commission of Fair Trading. “Whilst technical machine testing of these products might show them to have a lower level of toxicants, our investigations suggest that the impact of human behaviour results in there being little difference between the intake of toxicants from these products and their regular-strength counterparts.

During the investigation, British American Tobacco and Imperial Tobacco gave the commission assurances that they would remove the descriptors from their packaging. Philip Morris has planned to do the same by 17 October.

Meanwhile, the parliamentary health select committee has recommended the banning of tobacco and cigarette displays in shops. The committee’s report, issued on 29 September, found that displays could “create a false impression of the safety, social acceptability, and prevalence of tobacco use“. (pi)

Smoking Help Goes Online | 23 September 2008

Smokers in Scotland will be able to get live assistance online to help them kick the habit, NHS Scotland has announced.

A website, called Can Stop Smoking, is being launched which will have advisors online between 18:00 and 20:00 to offer advice on giving up cigarettes.

The online service will run in addition to a telephone offering which is already in use.

‘The Smokeline telephone advice line as proved popular in the past and I’m sure that making use of new technology will enable even more people to access these services and take the first vital step to becoming a non-smoker,’ said Shona Robison, minister for public health.

More than 13,000 Scots die each year from smoking, the Scottish Government claims, with 1,000 of these from passive smoking.

The country has taken large steps in the last through years to deal with smoking-related diseases, including becoming the first UK country to introduce a ban on smoking in enclosed public spaces in 2006.

Passive Smoking Ups Risk Of PAD By 50% CME

News Author: Lisa Nainggolan – CME Author: Laurie Barclay, MD – From Heartwire — a professional news service of WebMD | September 22, 2008

Chinese researchers have reported, for the first time, a link between exposure to passive smoke and peripheral arterial disease (PAD) in a cohort of women who have never smoked. Dr Yao He (Chinese PLA General Hospital, Beijing, China) and colleagues publish their findings today in Circulation [1].

“We found that compared with women who were not exposed to secondhand smoke (SHS), among women who were exposed to SHS, the risk of intermittent claudication was increased by 87% and risk of PAD — assessed by ankle-brachial index < 0.90 — was increased by 47%, with significant dose-response relationships for both number of cigarettes exposed to and duration of exposure,” they state.

In line with previous studies, He et al also found an increased risk of both coronary heart disease and stroke in the women exposed to passive smoking, with this being the first study to specifically report a positive association between SHS and ischemic but not hemorrhagic stroke.

“In China, only 4% of women are current smokers, but more than 50% of women are exposed to SHS,” they note. “But most people [there] are unaware of the serious health hazards of SHS. Thus, urgent public health measures are warranted to protect individuals from exposure to SHS.”

Passive smoking linked with ischemic, but not hemorrhagic stroke

The researchers explain that China is the largest producer and consumer of tobacco in the world, with its 350 million smokers puffing their way through 30% of the globe’s cigarettes. But awareness of the health hazards of either active or passive smoking is still low.

They set out to examine the relationship between SHS and cardiovascular diseases, particularly PAD and stroke, in older Chinese women (60 years or older) who had never smoked from a population-based cross-sectional study in Beijing. SHS was defined as exposure to another person’s tobacco smoke at home or in the workplace.

“Because the vast majority of women were never smokers (87%) we had a unique opportunity to evaluate the association of SHS with risk of CVD [cardiovascular disease], particularly PAD,” they note.

After adjustment for 13 potential confounding factors, they found that women who had been exposed to SHS had a significantly higher risk of coronary heart disease (CHD; adjusted odds ratio [OR] 1.69; p<0.001) and ischemic stroke (OR 1.56; p = 0.035) than those never exposed to SHS.

The adjusted OR’s of PAD defined by intermittent claudication (IC), by ankle-brachial index (ABI) < 0.90 and by either IC or ABI < 0.90 were: 1.87 ( p=0.001), 1.47 (p=0.018) and 1.67 (p<0.001) respectively.

Dose-response relationships were found between SHS exposure amount (cigarettes per day) and duration (minutes per day) and increasing prevalence of CHD, ischemic stroke and PAD.

“Our finding of a dose-dependent association of SHS with CHD is consistent with the literature,” He et al explain. They also note that their findings with regard to stroke support previous studies, but that many of these did not investigate subtypes of stroke.

“This population based study is the first to report a positive association of SHS exposure with ischemic stroke but not hemorrhagic stroke among Chinese female nonsmokers.”

PAD underdiagnosed and undertreated in China

An important advantage of the study, say He et al, was that PAD was diagnosed by ABI measurement. They explain that PAD is an underdiagnosed and undertreated condition in China: previous studies have shown almost 50% of PAD patients are asymptomatic and most of them are unaware of their condition.

“To the best of our knowledge, this is the first study showing an increased risk of PAD with increasing SHS exposure,” they note, adding that they believe their results are generalizable to similar populations in China.

“SHS exposure in women is highly prevalent in China. In addition to being a causal factor for CHD, SHS should be considered an important risk factor for ischemic stroke and PAD in Chinese women who never smoked,” they conclude.

This study is supported by research grants from the National Natural Science Foundation of China, Beijing Natural Science Foundation, and the Health Service in the Health Ministry of China. Dr Hu was partly supported by an American Heart Association Established Investigator Award. Coauthor Dr. He was partly supported by the Gordon Wu and Cheng YuTung Exchange Professorships in the Faculty of Medicine at the University of Hong Kong. The other study authors have disclosed no relevant financial relationships.


1. He Y, Lam TH, Jian B et al. Passive smoking and risk of peripheral arterial disease and ischemic stroke in Chinese women who never smoked. Circulation. 2008:doi: 10.1161/CIRCULATIONAHA.108.784801.

Clinical Context

There is strong evidence to date that SHS exposure is a causal factor for CHD. However, the relationship between SHS exposure and ischemic stroke and PAD is still unclear.

Several studies suggest a positive association between SHS and the risk for stroke. There have been recent estimates of the prevalence of PAD attributable to active smoking in a Chinese population, but no study to date has reported on the association of SHS with PAD.

The complete contents of Heartwire, a professional news service of WebMD, can be found at, a Web site for cardiovascular healthcare professionals.

Medscape Medical News 2008. ©2008 Medscape

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Philip Morris Limited’s Response to the Department of Health’s Consultation on the Future of Tobacco Control

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