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Smokers get lung cancer reminder

The Sydney Morning Herald November 22, 2007

Victorian health authorities will recycle a confronting anti-smoking campaign, after new research revealed most smokers did not identify lung cancer as a disease they could develop.

Research from the Cancer Council Victoria shows that despite smoking accounting for 80 per cent of all lung cancer cases, six in 10 smokers did not mention it when asked to name diseases caused by smoking.

The five-year survival rate for lung cancer sufferers is just 11 per cent, and 34 Victorians each week die from the disease, according to the Cancer Council.

The council’s Professor David Hill said deaths from lung cancer had decreased in recent years, though more specific data was not immediately available.

The council and anti-smoking body Quit on Monday relaunched their 23-year-old television advertisement showing a smoker’s lung, represented by a sponge, filling with tar and being squeezed out into a beaker.

Also, the Victorian government announced an extra $5.6 million boost to anti-smoking marketing.

Victorian Premier John Brumby said advertising was proving to be an effective tool in the fight against smoking with 46 per cent of successful quitters listing mass media as a prompt for quitting.

The government aims to reduce Victoria’s smoking rate from 17.4 per cent to 14 per cent by 2013.

Higher targets will be set for disadvantaged groups, including Aborigines, whose smoking rates are higher.

The figures show the proportion of smokers who spontaneously identified smoking as a cause of lung cancer had decreased by 25 per cent over three years.

Quit executive director Fiona Sharkie said “reinventing” the sponge campaign would help deliver the lung cancer message to a new generation of smokers.

“Back in the early 80s there were no distinct trends that we could really identify in smoking rates … about a third of the population were smokers,” Ms Sharkie said.

“But the original sponge ad was a real turning point on tobacco control, it was the first time smokers were shown the effects smoking had on their health in a graphic and uncompromising way.

“And as a result of that, smoking rates dropped significantly.”

Victorian Health Minister Daniel Andrews said the data showed more work was needed to stop people smoking and the extra money announced on Monday would bring the government’s total expenditure on social marketing and Quit campaigns to $10 million.

Non-smokers the big winners when it comes to smoking bans

Medical Studies/Trials
Published: Thursday, 22-Nov-2007

American scientists have found that heart attacks decreased after a smoking ban was imposed but this only applied to non-smokers.

Their study suggests that the major benefit of the ban on smoking in public places is being seen in nonsmokers.

The researchers from Indiana University say even those with no risk factors for heart disease can still experience heart attacks but after a countywide smoking ban was implemented, hospital admissions for such heart attacks dropped 70 percent for non-smokers, but not for smokers.

The researchers conducted the study in order to investigate whether smoking bans led to any changes in hospital admissions for myocardial infarction (MI).

They did this by comparing hospital admissions for MI in Monroe County, Indiana, which has had a public smoking ban in place since August 2003, with those in Delaware County, also in Indiana, which has much in common with Monroe Country but does not have a smoking ban.

Dong-Chul Seo, lead author and an assistant professor in IU Bloomington’s Department of Applied Health Science, says heart attack admissions for smokers saw no similar decline during the study, so the benefits of the ban appear to come more from the reduced exposure to second-hand smoke among non-smokers than from reduced consumption of tobacco among smokers.

The study is the first to examine the effect of public smoking bans on heart attacks in non-smokers.

Previous studies did not distinguish between non-smokers and smokers when examining the effect of the bans or specifically look at non-smokers who had no risk factors for heart disease, such as high blood pressure, high cholesterol or previous heart surgery.

Experts say exposure to second-hand smoke for just 30 minutes can rapidly increase a person’s risk for heart attack, even if they have no risk factors because the smoke, which contains carbon monoxide, causes blood vessels to constrict and reduces the amount of oxygen that can be transported in the blood.

The researchers say it is of concern that about half of all non-smoking Americans are regularly exposed to second-hand smoke, even though more than 500 municipalities nationwide have adopted some form of a smoking ban in public places.

The study also compared the hospital admissions in Monroe county before and after the smoking ban was adopted and found there was a 70 percent drop in the number of hospital admissions for AMI among non-smoking patients with no history of heart disease.

The study is published in the latest issue of the Journal of Drug Education.

Second hand smoke – what is the risk to your health?

“Public health officials have concluded that secondhand smoke from cigarettes causes disease, including lung cancer and heart disease, in non-smoking adults, as well as causes conditions in children such as asthma, respiratory infections, cough, wheeze, otitis media (middle ear infection) and Sudden Infant Death Syndrome. In addition, public health officials have concluded that secondhand smoke can exacerbate adult asthma and cause eye, throat and nasal irritation.”

Source: Philip Morris International website

The real cost of cigarettes to smokers: $222 a pack

Published by Vanderbilt University on the 11th of November 2007:

The real cost of cigarettes to smokers: $222 a pack;
Vanderbilt professors estimate the economic effect smoking has on smokers

How much does a pack of cigarettes really cost a smoker? While past studies have focused on the cost of cigarette smoking to society, a new report by two Vanderbilt University professors looks at the cost of smoking per pack in terms of the value of the risks to the smoker’s life.

University Distinguished Professor of Law, Economics, and Management W. Kip Viscusi and Professor of Law and Economics Joni Hersch found that each pack of cigarettes a man smokes reduces the value of his life by $222. For women, the results are $94 per pack.

“The data illustrates that smoking dwarfs almost every other risk people take,” Viscusi said. Viscusi is one of the leading authorities on cost-benefit analysis and the author of Smoke-Filled Rooms: A Post-Mortem on the Tobacco Deal.

The study results would seem to differ from Viscusi’s earlier findings that the cost of smoking to society is reduced due to smokers’ earlier deaths. But this study is different because it takes into account the cost to the smokers themselves based on the value smokers put on their own lives rather than the financial costs to society.

Previous research only considered the increased risk of dying at the end of life, whereas Viscusi and Hersch take note that smoking increases a person’s chances of dying at any time in his or her life. And, though it seems counterintuitive, the research finds that the value that a 20-year-old places on reducing the risk of death is actually lower than a 50-year-old’s. Although 20-year-olds have more of their life at risk, they are less affluent than 50-year-olds and consequently value safety less.

Why is the cost lower for women than for men? Viscusi and Hersch said it’s because men typically earn more than women over their lifetimes and have a greater mortality risk from smoking.

While it may be tempting for pundits to use this new analysis as an excuse for higher cigarette taxes, Viscusi said the data serve to reinforce the result that the main costs of smoking are not to society but to the smokers themselves. His past studies of smokers’ risk beliefs show that smokers already overestimate the risk of smoking, but smoke anyway. The question then, said Viscusi, is whether smokers really do like to smoke and also are just more likely to live in the present moment.

Despite the current focus on obesity, Viscusi said the bottom line is still that smoking is one of the worst risks people take with their health.

Particulate Air Pollution Short Term Effects

School of Public Health, The University of Hong Kong, Hong Kong, China.

BACKGROUND: Numerous studies have shown that ambient air pollution and smoking are both associated with increased mortality, but until now there has been little evidence as to whether the effects of these 2 factors combined are greater than the sum of their individual effects. We assessed whether smokers are subject to additional mortality risk from air pollution relative to never-smokers.

METHODS: This study included 10,833 Chinese men in Hong Kong who died at the age of 30 or above during the period 1 January to 31 December 1998. Relatives who registered for deceased persons were interviewed about the deceased’s smoking history and other personal lifestyle factors about 10 years before death. Poisson regression for daily number of deaths was fitted to estimate excess risks per 10 microg/m increase in particulate matter with aerodynamic diameter <10 microm (PM10) in male smokers and never-smokers in stratified data, and additional excess risk for smokers relative to never-smokers in combined data.

RESULTS: In smokers there was a significant excess risk associated with PM10 for all natural causes and cardio-respiratory diseases for men age 30 years or older and men 65 or older. For all natural causes, greater excess risk associated with PM10 was observed for smokers relative to never-smokers: 1.9% (95% confidence interval = 0.3% to 3.6%) in men age 30 and older and 2.3% (0.4% to 4.3%) in those age 65 and older.

CONCLUSIONS: Ambient particulate air pollution is associated with greater excess mortality in male smokers compared with never-smokers.

Risk of Exposure to Secondhand Tobacco Smoke Outdoors

Stanford University – 2nd May 2007

Study confirms the risk of exposure to secondhand tobacco smoke outdoors

Tens of thousands of Americans die each year from secondhand tobacco smoke, according to a 2006 report by the U.S. Surgeon General. While the health risks associated with indoor secondhand smoke are well documented, little research has been done on exposure to toxic tobacco fumes outdoors.

Now, Stanford University researchers have conducted the first in-depth study on how smoking affects air quality at sidewalk cafés, park benches and other outdoor locations. Writing in the May issue of the Journal of the Air and Waste Management Association (JAWMA), the Stanford team concluded that a non-smoker sitting a few feet downwind from a smoldering cigarette is likely to be exposed to substantial levels of contaminated air for brief periods of time.

“Some folks have expressed the opinion that exposure to outdoor tobacco smoke is insignificant, because it dissipates quickly into the air,” said Neil Klepeis, assistant professor (consulting) of civil and environmental engineering at Stanford and lead author of the study. “But our findings show that a person sitting or standing next to a smoker outdoors can breathe in wisps of smoke that are many times more concentrated than normal background air pollution levels.”

Klepeis pointed to the 2006 Surgeon General’s report, which found that even brief exposures to secondhand smoke may have adverse effects on the heart and respiratory systems and increase the severity of asthma attacks, especially in children.

“We were surprised to discover that being within a few feet of a smoker outdoors may expose you to air pollution levels that are comparable, on average, to indoor levels that we measured in previous studies of homes and taverns,” said Wayne Ott, professor (consulting) of civil and environmental engineering at Stanford and co-author of the JAWMA study. “For example, if you’re at a sidewalk café, and you sit within 18 inches of a person who smokes two cigarettes over the course of an hour, your exposure to secondhand smoke could be the same as if you sat one hour inside a tavern with smokers. Based on our findings, a child in close proximity to adult smokers at a backyard party also could receive substantial exposure to secondhand smoke.”

Unlike indoor tobacco smoke, which can persist for hours, the researchers found that outdoor smoke disappears rapidly when a cigarette is extinguished. “Our data also show that if you move about six feet away from an outdoor smoker, your exposure levels are much lower,” Klepeis added.

The public has become increasingly concerned about the effects of outdoor smoking, Ott noted. More than 700 state and local governments have passed laws restricting outdoor smoking at playgrounds, building entrances and other public areas, according to the American Nonsmokers’ Rights Foundation. Some of the strictest ordinances are in California. The city of Santa Monica, for example, recently banned smoking at parks, beaches, ATM machines, theater lines, open-air restaurants and other outdoor locations.

“Throughout the country, cities and counties are looking at various laws against outdoor smoking, and some of the proposals are pretty drastic,” Ott said. “The problem is that until now, there have been virtually no scientific data to justify such restrictions. In fact, our paper is the first study on outdoor smoking to be published in a peer-reviewed scientific journal.”

Particulate matter

In the study, the researchers used portable electronic monitors to make precise measurements of toxic airborne particles emitted from cigarettes at 10 sites near the Stanford campus. “We wanted to quantify the potential level of exposure to outdoor tobacco smoke that could occur in everyday settings,” Klepeis said. “To do this, we used five different, state-of-the-art instruments to measure secondhand smoke at parks, open-air cafes, sidewalks and outdoor pubs where smokers were present.”

Each instrument was calibrated to measure an airborne pollutant known as particulate matter-2.5 (PM2.5), which consists of thousands of microscopic particles that are less than 2.5 micrometers in width–about 30 times narrower than a human hair.

“PM2.5 is a toxic pollutant produced by cigarettes, wood-burning stoves, diesel engines and other forms of combustion,” Ott explained. “It contains benzo(a)pyrene, a carcinogen, and many other toxic chemicals that can penetrate deep inside the lungs.”

According to the Environmental Protection Agency, exposure to PM2.5 can lead to serious health problems, including asthma attacks, chronic bronchitis, irregular heartbeat, nonfatal heart attacks and even premature death in people with heart or lung disease. The current EPA ambient air standard for PM2.5 is 35 micrograms per cubic meter of air averaged over 24 hours. Levels that exceed 35 micrograms are considered unhealthy “However, since tobacco smoke contains many toxic components, including carcinogens, it may be even less healthy than typical ambient air pollution,” Klepeis noted.

Test results

To measure PM2.5 levels in secondhand smoke, the researchers placed the instruments near actual smokers in different open-air environments. “We also performed controlled experiments with burning cigarettes, which allowed us to make precise measurements of PM2.5 levels at different distances,” Klepeis said.

The results were clear: The closer you are to an outdoor smoker, the higher your risk of exposure.

“A typical cigarette lasts about 10 minutes,” Klepeis said. “We found that if you’re within two feet downwind of a smoker, you may be exposed to pollutant concentrations that exceed 500 micrograms of PM2.5 over that 10-minute period. If you’re exposed multiple times to multiple cigarettes over several hours in an outdoor pub, it would be possible to get a daily average of 35 micrograms or more, which exceeds the current EPA outdoor standard.”

Outdoor tobacco smoke consists of brief plumes that sometimes exceed 1,000 micrograms, Klepeis added. “On the other hand, clean air typically contains less than 20 micrograms of PM2.5,” he said. “Therefore, a person near an outdoor smoker might inhale a breath with 50 times more toxic material than in the surrounding unpolluted air.”

However, the researchers found that air quality improved as they moved away from the smoker. “These results show what common sense would suggest–when you’re within a few feet downwind of a smoker, you get exposed,” Ott explained. “But likewise, when you go a little distance or stay upwind, the exposure goes way down. If there’s just one smoker, and you can sit six feet away, you would have little problem. At the same time, if there are a lot of smokers nearby, you may be exposed to very high levels of secondhand smoke. So this thing that critics have been dismissing as trivial is not.”

Added Klepeis: “If people realize that being near outdoor smokers can result in potentially large exposures to toxic air pollution, they may decide they do not wish to be exposed in a variety of outdoor settings. This realization may lead to an increased number of smoking bans in public locations.”

Passive Smoking Risks in Catering Industry

Published by Oxford University Press on behalf of the Society of Toxicology on the 20th of January 2006: 

Risks for Heart Disease and Lung Cancer from Passive Smoking by Workers in the Catering Industry

Workers in the catering industry are at greater risk of exposure to secondhand smoke (SHS) when smoke free workplace policies are not in force. We determined the exposure of catering workers to SHS in Hong Kong and their risk of mortality from heart disease and lung cancer. Non-smoking catering workers were provided with screening at their workplaces and at a central clinic. Participants reported workplace, home and leisure time exposure to SHS. Urinary cotinine was estimated by enzyme immunoassay. Catering facilities were classified into three types: non-smoking, partially restricted smoking (with non-smoking areas) and unrestricted smoking. Mean urinary cotinine levels ranged from 3.3 ng/ml in a control group of 16 university staff, through 6.4 ng/ml (non smoking), 6.1 ng/ml (partially restricted) and 15.9 ng/ml (unrestricted smoking) in 104 workers who had no out of work exposures. Workers in non-smoking facilities had exposures to other smoking staff. We modeled workers’ mortality risks using average cotinine levels, estimates of workplace respirable particulates, risk data for cancer and heart disease from cohort studies, and national (US) and regional (Hong Kong) mortality for heart disease and lung cancer. We estimated that deaths in the Hong Kong catering workforce of 200,000 occur at the rate of 150 per year for a forty year working life time exposure to SHS. When compared with the current outdoor air quality standards for particulates in Hong Kong, 71% of workers exceeded the 24 hour and 98% exceeded the annual air quality objectives due to workplace SHS exposures.

Cost of tobacco-related diseases

RESEARCH PAPER

Cost of tobacco-related diseases, including passive smoking, in Hong Kong

S M McGhee1, L M Ho1, H M Lapsley2, J Chau1, W L Cheung1, S Y Ho1, M Pow1, T H Lam1, A J Hedley1

1 Department of Community Medicine, University of Hong Kong, Hong Kong SAR, China
2 Centre of National Research on Disability and Rehabilitation Medicine, The University of Queensland, Brisbane, Queensland, Australia

Correspondence to:

Professor Anthony J Hedley
Department of Community Medicine, University of Hong Kong, William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China; commed@hkucc.hku.hk Background: Costs of tobacco-related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking.

Aim: To estimate the health-related costs of tobacco from both active and passive smoking.

Methods: Using local data, we estimated active and passive smoking-attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of US$1.3 million for a life lost.

Results: In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was US$532 million for active smoking and US$156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to US$9.4 billion.

Conclusion: The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke-free areas in the Asia Pacific Region and elsewhere.

——————————————————————————–

Abbreviations: COPD, chronic obstructive pulmonary disease; IHD, ischaemic heart disease; LIMOR, University of Hong Kong Lifestyle and Mortality Study; OR, odds ratio; PAF, population attributable fraction; SAF, smoking-attributable fraction

Mortality associated with passive smoking in Hong Kong

BMJ 2005;330:287-288 (5 February), doi:10.1136/bmj.38342.706748.47 (published 27 January 2005)

S M McGhee, associate professor1, S Y Ho, research assistant professor1, M Schooling, research associate1, L M Ho, senior computer manager1, G N Thomas, research assistant professor1, A J Hedley, chair professor1, K H Mak, consultant, community medicine2, R Peto, professor of medical statistics and epidemiology3, T H Lam, chair professor and head of department1

1 Department of Community Medicine, University of Hong Kong, 21 Sassoon Road, Pokfulam, Hong Kong, China, 2 Department of Health, Student Health Service, 4/F Lam Tin Polyclinic, Kowloon, Hong Kong, China, 3 Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX2 6HE

Correspondence to: T H Lam hrmrlth@hkucc.hku.hk

Introduction

Passive smoking can cause death from lung cancer and coronary heart disease, but there is little evidence for associations with other causes of death in never smokers. A recent study showed increased all cause mortality with exposure to secondhand smoke at home but did not examine associations with specific causes of death and dose-response relations.1 We have published estimates of the mortality attributable to active smoking in Hong Kong2 and now present the related findings on passive smoking at home.

Participants, methods, and results

Details of the sample selection and data collection have been reported.2 Each person who reported a death in 1998 at four death registries was given a questionnaire which asked about the lifestyle 10 years earlier of the decedent and of a living person about the same age who was well known to the informant. Passive smoking was identified in the interview with the question, “Ten years ago, in about 1988, excluding the decedent/control, how many persons who lived with the decedent/control smoked?” Decedents or controls who lived with one or more smokers were classed as exposed. Cause of death was obtained from the death certificate.

We selected never smoking decedents and controls aged 60 years or over because there were few younger controls. To avoid selection bias, we included only cases and controls who had a living spouse at the time of reporting. We used logistic regression to derive odds ratios adjusted for age and education, and for sex when men and women were combined.

What is known on this topic

There is strong evidence that passive smoking is causally associated with death from lung cancer, coronary heart disease, and all causes, and also with acute stroke

What this study adds

The dose-response relation between passive smoking and mortality from stroke and chronic obstructive pulmonary disease, as well as from lung cancer, ischaemic heart disease, and all causes of death, strengthens the causal link

We identified 4838 never smoking cases (55% male) and 763 never smoking controls (55% male). All controls were used in the analysis for each specific cause of death.

We found significant dose dependent associations between passive smoking and mortality from lung cancer, chronic obstructive pulmonary disease, stroke, ischaemic heart disease, and from all cancers, all respiratory and circulatory diseases, and all causes (table). The association between mortality and passive smoking did not differ between males and females. Deaths due to injury or poisoning were not associated with passive smoking.

View this table:
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Number of subjects who were or were not exposed to secondhand smoke at home and odds ratios (adjusted for age and education, and for sex when men and women were combined) for mortality in people aged 60 or over, Hong Kong. Values are odds ratio (95% confidence interval) unless indicated otherwise

Comment

Dose dependent associations between passive smoking and causes of death are consistent with previous findings for lung cancer and coronary heart disease and extend the evidence on stroke. Previous studies have shown associations between passive smoking and first acute strokes,3 4 and we have now shown a dose-response relation with mortality from stroke. Previous studies focused on ischaemic strokes but Chinese populations have a greater incidence of haemorrhagic stroke than do white populations,5 implying that many of the strokes in our study may have been non-ischaemic. Passive smoking probably affects all stroke subtypes, as does active smoking.

Our finding of a 34% increase in all cause mortality is consistent with but higher than that (15%) in the New Zealand cohort.1 Exposure to secondhand smoke at home is higher in Hong Kong than in New Zealand due to crowded living conditions. Before the 1990s, awareness of the danger of passive smoking was lower and smokers smoked freely at home.

We focused on passive smoking at home because the proxy reporter could most reliably supply these data, and we adjusted for education, which was also reliably recorded2 and is a good proxy for social class in Hong Kong. As data on cases and controls were derived from the same proxy, reporting bias should be minimal.2 If our results are not due to residual confounding, they provide further evidence that the dose-response associations between passive smoking and stroke and all cause mortality are likely to be causal.

See Editorial by Kawachi

This article was posted on bmj.com on 27 January 2005: http://bmj.com/cgi/doi/10.1136/bmj.38342.706748.47

We thank W L Cheung for help with analysis; the Immigration Department of the Government of the Hong Kong Special Administrative Region for data and assistance; and, in particular, the relatives who provided information.

Contributors: THL, SYH, AJH, KHM, and RP designed and carried out the study on which this analysis was based; SMcG, MS, LMH, and GNT planned and carried out this analysis; and all authors contributed to writing the paper. SMcG and THL are guarantors.

Funding: Hong Kong Health Services Research Committee (#631012) and Hong Kong Council on Smoking and Health.

Competing interests: THL is vice chairman and AJH a former chairman of the Hong Kong Council on Smoking and Health.

Ethical approval: Ethics Committee of the Faculty of Medicine, University of Hong Kong.

References
1. Hill SE, Blakely TA, Kawachi I, Woodward A. Mortality among never smokers living with smokers: two cohort studies, 1981-4 and 1996-9. BMJ 2004;328: 988-9.[Free Full Text]
2. Lam TH, Ho SY, Hedley AJ, Mak KH, Peto R. Mortality and smoking in Hong Kong: case-control study of all adult deaths in 1998. BMJ 2001;323: 361-2.[Abstract/Free Full Text]
3. Bonita R, Duncan J, Truelson T, Jackson RT, Beaglehole R. Passive smoking as well as active smoking increases the risk of acute stroke. Tobacco Control 1999;8: 156-60.[Abstract/Free Full Text]
4. Iribarren C, Darbinian J, Klatsky AL, Friedman GD. Cohort study of exposure to environmental tobacco smoke and risk of first ischemic stroke and transient ischemic attack. Neuroepidemiology 2004;23: 38-44.[CrossRef][ISI][Medline]
5. Kay R, Woo J, Kreel L, Wong HY, Teoh R, Nicholls MG. Stroke subtypes among Chinese living in Hong Kong: the Shatin stroke registry. Neurology 1992;42: 985-7.[Abstract/Free Full Text]

(Accepted 12 August 2004)

Secondhand Smoke Exposure

Secondhand Smoke Exposure

S.M. McGhee, A.J. Hedley
Department of Community Medicine, University of Hong Kong, Hong Kong SAR, China

The smoke from a burning cigarette contains a toxic mix of chemical substances and the IARC has classed secondhand tobacco smoke (SHS) as a Group 1 carcinogen. The evidence of harm to adult passive smokers is mounting including lung cancer and respiratory illness, heart disease and stroke as well as more minor acute respiratory symptoms and irritation. Children are even more vulnerable with domestic exposures before and/or after birth resulting in low weight infants, chronic health problems and more frequent hospital admissions for respiratory disease. There is also evidence of damage to lipoproteins in children although much of the longer term harm has not yet been assessed.

For adults, the workplace has been a common site of exposure but, in many countries, smoke-free workplaces are becoming more common. In the developing world however, SHS remains as occupational hazard, In Hong Kong, non-smoking catering workers had urine cotinine levels which indicated a 3% increased risk of mortality from heart disease or lung cancer compared with a level of 0.1% for the US occupational health significant risk level.

Policy-makers everywhere need to protect non-smokers from this serious threat to their respiratory and cardiovascular health and thus protect their communities from serious economic loss.