Physicians key players in tobacco control, including curbing secondhand smoke exposure
Dr K K Aggarwal and Dr S S Agarwal
Secondhand smoke is a well-recognized health hazard. Secondhand smoke is smoke that is exhaled by the person who smokes (mainstream smoke) or emitted from burning cigarettes, cigars or pipes (side stream smoke). Breathing in this smoke is called passive smoking.
Mainstream smoke contains more than 4000 chemicals, including chemical irritants and about 70 carcinogens. Side stream is dangerous because while it has a composition similar to mainstream smoke, the concentration of toxins and carcinogens is often higher.
Secondhand smoke increases the risk for respiratory infections, asthma, COPD, lung cancer and heart disease. The longer the duration of exposure, the greater the level of harmful substances in the body. Children, in particular are vulnerable to the effects of exposure to second hand smoke. Homes and vehicles are the main places of exposure for children. For adults it is their work place or social environments.
According to the American Lung Association, secondhand smoke causes approximately 7,330 deaths from lung cancer and 33,950 deaths from heart disease each year in the United States. The Cleveland Clinic website mentions the following effects of second hand smoke in relation to exposure time.
· Exposure for 5 min stiffens the aorta as much as smoking a cigarette.
· Exposure for 20-30 min causes excess blood clotting, and increases the build-up of plaques in blood vessels thereby increasing the risk of heart attack and stroke
· Exposure for 2 hours increases the risk of arrhythmia and can trigger a fatal cardiac event or heart attack.
Article 8 of the WHO Framework Convention on Tobacco Control requires the adoption of effective measures to protect people from exposure to tobacco smoke in indoor workplaces, indoor public places, public transport and ‘as appropriate’ in ‘other public places’. Guidelines for implementation of WHO Framework Convention on Tobacco Control state that ‘no safe levels of exposure to second-hand smoke exist’ and ventilation, air exchange including use of designated smoking areas, do not protect against exposure to tobacco smoke. Creating a 100% smoke-free environment is the only way to provide protection from exposure to tobacco smoke.
In the year 2005, India became a Party to the WHO Framework Convention on Tobacco Control. In 2008 the Ministry of Health and Family Welfare notified the Prohibition of Smoking in Public Places Rules, 2008 by which smoking in public places was prohibited and a person violating this would be required to pay a fine of Rs 200/-. In January 2015, the Union Health Ministry proposed the Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) (Amendment) Bill 2015 under which it recommended increasing the fine from Rs 200/- to Rs 1000/- on smoking in public places and removal of designated smoking zones in hotels and restaurants. It also proposed a ban on sale of loose cigarettes and raising the minimum age of a person buying tobacco products to 21 years from existing 18 years.
Second hand or passive smoking is a serious public health problem and needs to be tackled. All stakeholders – healthcare professionals, policy makers and public – need to be actively involved. According to the WHO, unless urgent action is taken, tobacco use and exposure to second-hand smoke (SHS) will cause over 8 million deaths by the year 2030. Tobacco could claim up to one billion lives globally in the 21st century.
Physicians have a key role to play in tobacco control including control of second hand smoke exposure. As healthcare providers, they occupy a unique position in the society to educate people about dangers of tobacco use and exposure to second-hand smoke and support tobacco control efforts initiated by the government. Not only physicians as individuals, but also medical associations too should take up leadership roles in such initiatives. Continuing educating on tobacco control for physicians therefore assumes significance.
The World Medical Association (WMA) has made available a new online course for physicians to help them assess the health effects of second hand tobacco smoke on children's health. The course has been developed by the School of Policy, Government and International Affairs at George Mason University in Arlington, Virginia, USA in collaboration with the WMA. The course helps physicians to explore intervention methods and legislation to minimize tobacco smoke exposure for infants and children and understand the existing evidence. It is recommended that all physicians try to undertake this course. Physician driven advocacy to the government could also lead to better legislative impetus to curbing the consumtpion, and adding to the arsenal of tools including price control to not only reduce secondhand smoke exposure but also active primary smoking.
Sir Michael Marmot, president of WMA said, “Physicians have to do more to press for smoking bans and tobacco free environments. Millions of children are breathing air polluted by tobacco smoke. We can intervene on behalf of infants and children and we must”. Physicians should individually and collectively start educating the community about smoking and its major downside risks to health.