The Perils of Smoke

Billowing smoke is a warning the community dreads and the call to action for firefighters. Where there’s smoke, there’s fire, but the Clean Air Act is ambivalent on incineration as it bans voluntary burning of trash in urban areas but consents in rural settings. Health authorities even urge smoke production as a means of dengue control.

But even the languid smoke wafting from the glow of a cigarette stick can be equally deadly to everyone in an enclosed space, children being the most vulnerable. Whatever raised the sudden alarm, six lawmakers are reported to be leading a bipartisan effort at the House of Representatives to pass legislation designed to scare smokers into quitting.

Led by Northern Samar Representative Paul Daza, the group is pushing a bill that would require tobacco companies to place “picture warnings” on their products to illustrate the dangers of smoking. The warnings will include images of tumors, diseased lungs and other graphic ill effects of the vice on smokers as well as the victims of second-hand smoke.

In a more pointed campaign, visitors to southern Philippines city of Davao get more than just a welcome message. Flight passengers for instance, would hear this admonition just before touchdown: "Welcome to Davao. We would like to inform you that there is a smoking ban in Davao City which is implemented in all public places and all transportation vehicles."

Those who enter and leave Davao will see huge billboards stating that Davao is a smoke-regulated city. Smoking is not allowed in parks as these are considered recreational places frequented by minors. Tourism increased in Davao as a result of the smoking ban,

Fighting for a Smoke-free Philippines

IT’S tantamount to murder every day,” says a lawyer tobacco-control advocate referring to the plight of nonsmokers exposed daily to secondhand tobacco smoke. As the legal adviser of the Framework Convention on Tobacco Control Alliance Philippines (FCAP), the organization instrumental in the country’s ratification of the Framework Convention on Tobacco Control (FCTC), which is the world’s first global health treaty signed by over a hundred nations in 2005. As a signatory of the treaty, the Philippines is bound to implement its full measure come September 2008

The Philippines, along with 35 other countries, is participating in the drafting of a guideline for an international law on the implementation of visual health warning on the packaging of tobacco products. The Framework Convention of Tobacco Control (FCTC) is an international public health treaty of the World Health Organization. Its goal is to formulate an international law on tobacco control strategies. The Philippines is now discussing the guidelines in the implementation of Article 11 of the FCTC which has to do with the packaging of tobacco products.

What is causing the entire hubbub? The discovery that the smoke emanating from a cigarette smoker could cause a risk of cancer to non-smokers in an enclosed space or in his immediate vicinity. Following are excerpts culled from the Web:

Secondhand smoke, also known as environmental tobacco smoke (ETS) or passive smoke, is a mixture of two forms of smoke from burning tobacco products. Sidestream smoke is "smoke that comes from a lighted cigarette, pipe, or cigar" and Mainstream smoke is "smoke that is exhaled by a smoker." according to the American Cancer Society

The US Environmental Protection Agency (EPA) has classified secondhand smoke as a Group A carcinogen, which means that there is sufficient evidence that it causes cancer in humans. Environmental tobacco smoke has also been classified as a 'known human carcinogen' by the US National Toxicology Program.

Secondhand tobacco smoke contains over 4,000 chemical compounds. More than 60 of these are known or suspected to cause cancer.

What is Secondhand Smoke?

Secondhand smoke is a mixture of the smoke given off by the burning end of a cigarette, pipe, or cigar, and the smoke exhaled by smokers. Secondhand smoke is also called environmental tobacco smoke (ETS) and exposure to secondhand smoke is sometimes called involuntary or passive smoking. Secondhand smoke contains more that 4,000 substances, several of which are known to cause cancer in humans or animals.

EPA has concluded that exposure to secondhand smoke can cause lung cancer in adults who do not smoke. EPA estimates that exposure to secondhand smoke causes approximately 3,000 lung cancer deaths per year in nonsmokers.

Exposure to secondhand smoke has also been shown in a number of studies to increase the risk of heart disease.

Serious Health Risks to Children

Children are particularly vulnerable to the effects of secondhand smoke because they are still developing physically, have higher breathing rates than adults, and have little control over their indoor environments. Children exposed to high doses of secondhand smoke, such as those whose mothers smoke, run the greatest relative risk of experiencing damaging health effects.

Exposure to secondhand smoke

• can cause asthma in children who have not previously exhibited symptoms.


• increases the risk for Sudden Infant Death Syndrome.


• Infants and children younger than 6 who are regularly exposed to secondhand smoke are at increased risk of lower respiratory track infections, such as pneumonia and bronchitis.


• Children who regularly breathe secondhand smoke are at increased risk for middle ear infections.


• can cause new cases of asthma in children who have not previously shown symptoms.


• can trigger asthma attacks and make asthma symptoms more severe.

Key findings:

11% of children aged 6 years and under are exposed to ETS in their homes on a regular basis (4 or more days per week) compared to 20% in the 1998 National Health Interview Survey (NHIS).

Parents are responsible for 90% of children’s exposure to ETS.

Exposure to ETS is higher and asthma prevalence is more likely in households with low income and low education levels.

Children with asthma have as much exposure to ETS as children without asthma.

Respiratory Health Effects of Passive Smoking (Also Known as Exposure to Secondhand Smoke or Environmental Tobacco Smoke - ETS) (U.S. Environmental Protection Agency, 1992) Key findings:

In adults:

ETS is a human lung carcinogen, responsible for approximately 3,000 lung cancer deaths annually in U.S. nonsmokers. ETS has been classified as a Group A carcinogen under EPA's carcinogen assessment guidelines. This classification is reserved for those compounds or mixtures which have been shown to cause cancer in humans, based on studies in human populations.

In children:

ETS exposure

• increases the risk of lower respiratory tract infections such as bronchitis and pneumonia.


• increases the prevalence of fluid in the middle ear, a sign of chronic middle ear disease.


• in children irritates the upper respiratory tract and is associated with a small but significant reduction in lung function.


• increases the frequency of episodes and severity of symptoms in asthmatic children. The report estimates that 200,000 to 1,000,000 asthmatic children have their condition worsened by exposure to environmental tobacco smoke.


• is a risk factor for new cases of asthma in children who have not previously displayed symptoms.

Secondhand Smoke: Questions and Answers

National Cancer Institute FactSheet

Key Points Secondhand smoke (also called environmental tobacco smoke) is the combination of smoke given off by the burning end of a tobacco product and the smoke exhaled by the smoker Of the chemicals identified in secondhand smoke, more than 50 have been found to cause cancer Secondhand smoke causes lung cancer in nonsmokers. Secondhand smoke causes heart disease in adults and sudden infant death syndrome (SIDS), ear infections, and asthma attacks in children. There is no safe level of exposure to secondhand smoke.

What is secondhand smoke?

Secondhand smoke (also called environmental tobacco smoke) is the combination of sidestream smoke (the smoke given off by the burning end of a tobacco product) and mainstream smoke (the smoke exhaled by the smoker). Exposure to secondhand smoke is also called involuntary smoking or passive smoking. People are exposed to secondhand smoke in homes, cars, the workplace, and public places such as bars, restaurants, and other recreation settings. In the United States, the source of most secondhand smoke is from cigarettes, followed by pipes, cigars, and other tobacco products.

How is secondhand smoke exposure measured?

Secondhand smoke is measured by testing indoor air for nicotine or other smoke constituents. Exposure to secondhand smoke can be tested by measuring the levels of cotinine (a nicotine by-product in the body) in the nonsmoker’s blood, saliva, or urine (1). Nicotine, cotinine, carbon monoxide, and other evidence of secondhand smoke exposure have been found in the body fluids of nonsmokers exposed to secondhand smoke.

Does secondhand smoke contain harmful chemicals?

Yes. Of the more than 4,000 chemicals that have been identified in secondhand tobacco smoke, at least 250 are known to be harmful, and 50 of these are known to cause cancer. These chemicals include (1):

arsenic (a heavy metal toxin)

benzene (a chemical found in gasoline)

beryllium (a toxic metal)

cadmium (a metal used in batteries)

chromium (a metallic element)

ethylene oxide (a chemical used to sterilize medical devices)

nickel (a metallic element)

polonium–210 (a chemical element that gives off radiation)

vinyl chloride (a toxic substance used in plastics manufacture)

Many factors affect which chemicals are found in secondhand smoke, including the type of tobacco, the chemicals added to the tobacco, the way the product is smoked, and the paper in which the tobacco is wrapped

Does exposure to secondhand smoke cause cancer?

Yes. The U.S. Environmental Protection Agency (EPA), the U.S. National Toxicology Program (NTP), the U.S. Surgeon General, and the International Agency for Research on Cancer (IARC) have classified secondhand smoke as a known human carcinogen (cancer-causing agent)

Inhaling secondhand smoke causes lung cancer in nonsmoking adults. Approximately 3,000 lung cancer deaths occur each year among adult nonsmokers in the United States as a result of exposure to secondhand smoke. The Surgeon General estimates that living with a smoker increases a nonsmoker’s chances of developing lung cancer by 20 to 30 percent.

Some research suggests that secondhand smoke may increase the risk of breast cancer, nasal sinus cavity cancer, and nasopharyngeal cancer in adults, and leukemia, lymphoma, and brain tumors in children. Additional research is needed to learn whether a link exists between secondhand smoke exposure and these cancers.

What are the other health effects of exposure to secondhand smoke?

Secondhand smoke causes disease and premature death in nonsmoking adults and children. Exposure to secondhand smoke irritates the airways and has immediate harmful effects on a person’s heart and blood vessels. It may increase the risk of heart disease by an estimated 25 to 30 percent. There may also be a link between exposure to secondhand smoke and the risk of stroke and hardening of the arteries; however, additional research is needed to confirm this link.

Children exposed to secondhand smoke are at an increased risk of sudden infant death syndrome (SIDS), ear infections, colds, pneumonia, bronchitis, and more severe asthma. Being exposed to secondhand smoke slows the growth of children’s lungs and can cause them to cough, wheeze, and feel breathless.

What is a safe level of secondhand smoke?

There is no safe level of exposure to secondhand smoke. Studies have shown that even low levels of secondhand smoke exposure can be harmful. The only way to fully protect nonsmokers from secondhand smoke exposure is to completely eliminate smoking in indoor spaces. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot completely eliminate secondhand smoke exposure. This means separating the smoking area in planes is a palliative, the efficient air filtration system removes most micron size particles but not all.

Agony of quitting

Senator Barack Obama is using nicotine gum to help him quit smoking. Now the question is, can he quit the gum?

The Senator said he started using the nicotine gum Nicorette about nine months ago. That’s six months longer than the three months recommended on the gum package label. He is not the only quitter who is still seeking a nicotine fix months after giving up cigarettes. A small percentage of the people who use nicotine replacement products like gums, patches or lozenges end up hooked on a new habit, say doctors who specialize in smoking cessation. Smoking cessation experts say they hope Mr. Obama’s use of nicotine gum will encourage smokers to try a nicotine replacement product to help them quit. Although nicotine therapy doubles a smoker’s chance of successfully kicking the habit, use of the products remains relatively low. “The problem is not that people use it too much. The greater problem is that they use it too little. People use it for a week, and then they are back smoking cigarettes.”

People often don’t stick with nicotine gums and lozenges because they dislike the taste. Another concern is that many people think nicotine is what makes cigarettes harmful. But nicotine is what makes cigarettes addictive. The harm comes from the combustion and release of 40 known carcinogens and other toxic chemicals into your body every time you take a puff.

Last month, a study in the medical journal Addictive Behaviors noted that part of the problem is that nicotine gums and lozenges have stricter labeling requirements than cigarettes themselves. Cigarette packages usually contain one simple boxed warning about the health risks of cigarettes, but package labels on smoking cessation products come with detailed warnings about use and side effects. The language leaves the impression that products to stop smoking are as risky or riskier than cigarettes themselves.

Doctors say their goal is to get more people to try nicotine replacement products as an aid to help them kick the smoking habit. Most people won’t get hooked on the nicotine products, but a few people will. One gun user who quit smoking a year and a half ago but still uses nicotine gum says when he smells someone else’s smoke, he goes for the gum.

A doctor says that once someone has stopped smoking, he tries to encourage patients hooked on nicotine gum to start substituting real gum from time to time. Another doctor says he encourages people to wean themselves off nicotine gum once they’ve quit smoking. But given a choice between being on Nicorette gum or going back to smoking, there’s absolutely no question the gum is better.

Comments of former smokers:

Nicotine is one of the most difficult addictions to beat, aggravated by its being legal and widely used. Cold turkey works for some, but not all. Gum or patch is a steppingstone to becoming smoke-free. It helps to have encouragement and support if you are seriously seeking to quit. Speaking from experience…

I wish some news media would investigate and publish the use of capsules or tinctures of the herb lobelia inflata to help smokers stop…it is fast, within a week; total cost less than $10.00; and it works. It worked for me and for others who were smoking 2 and 3 packs a day…so why not research it, and then try it! It couldn’t hurt….another benefit is it lessens physical pain…

Well, the good news is that a UK listed company Meldex International has just launched (5 November 07) a pleasant tasting oral film strip that delivers a hit of nicotine in less than a minute. Vitually as fast as a cigarette. Launched incidentally in Poland and early next year in China and India. I think gum will eventually become like an obsolete technology…

Long story short, I inevitably began smoking again because I still needed the gum. Thank heaven it is no longer prescribed so people can get it and use it as long as it takes to stay smoke free –for a person who has been smoking for decades it is unrealistic to believe that three months is a long enough period to use the gum…

The senator would be delighted to learn that his quit-smoking approach was endorsed last month by Britain’s Royal College of Physicians, one of the world’s oldest and most prestigious medical societies (In 1962 the Royal College published the first comprehensive study of smoking and health, two years prior to the US Surgeon General’s first report).

The Royal College’s new report, entitled “Harm reduction in nicotine addiction: helping people who can’t quit.” (http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=234 ), provides hope for millions of inveterate smokers. It advocates a new approach called tobacco harm reduction, explaining “that smokers smoke predominantly for nicotine, that nicotine itself is not especially hazardous, and that if nicotine could be provided in a form that is acceptable and effective as a cigarette substitute, millions of lives could be saved

Harm reduction is a fundamental component of many aspects of medicine and indeed everyday life, yet for some reason effective harm reduction principles have not been applied to tobacco smoking. This report makes the case for radical reform to the way that nicotine products are regulated and used in society. The ideas presented are controversial, and challenge many current and entrenched views in medicine and public health. The principles behind them have the potential to save millions of lives. They deserve consideration. Nicotine is among the most powerful of addictive substances, but nicotine does not cause any smoking-related disease. In fact, nicotine itself is about as safe as caffeine, another addictive drug consumed safely by millions of Americans.

Brad Rodu

Professor of Medicine

Endowed Chair, Tobacco Harm Reduction Research

University of Louisville

Kudos to Dr. Rodu and his Tobacco Harm Reduction, Baton and his future “meldex”, all those who have managed to succeed against all ignorance in using nicotine (as harmless as caffeine) replacement therapy. What a shame that so few understand that tools are not ‘crutches’, willpower really is irrelevant for up to one half of smokers, and that replacement therapy is shamefully expensive. Some people need to start with 5 patches just to wean themselves. Studies have documented that many have alpha 7 nicotine receptors that take twice as long to desensitize, so the patch is useless, making the weaker gum more effective despite 3 times as long ’til relief, because it gives them needed spikes in nicotine levels. How many know that the gum and patch as directed have a pathetic 1 year success rate of under 14% while the spray is 89% effective and gives you a full 20th of what a cigarette does (in 2 minutes vs. 2 seconds). And that Chantix doesn’t warn that blocking nicotine uptake can make a small % of people broken or suicidal in mere days, but it helps the majority quit very quickly. And that there are blood tests to determine how much you are self-medicating with nicotine and thus what level of replacement to start at. Falling off the wagon can grow a bunch of hungry new neuroreceptors overnight, so health insurance and the government should subsidize these treatments that are (poorly) known to work, because billions of health $$ would be saved. I salute all who quit, and even more those who have had to use expensive trial and error (unnecessarily) to find the right nicotine replacement for them - no matter how long they have to stay on it. Pulmonary Diag. and Rehab Group in Palo Alto is an example of the too rare clinic (also did the trials for FDA approval of Nicotrol spray and Chantix) that can tell you that YES you CAN stop FOR GOOD this time without going nuts, by giving you enough replacement to prevent withdrawal from trashing your life. I suspect all those stubborn smokers who still smoke ‘for pleasure’ would immediately quit if they had access to current protocols and replacement therapy costing the same as coffee. I know multimillionaires on their 10th year of the gum, so I SALUTE Obama and people like him for their trail blazing inspiration! Good luck future ex-smokers everywhere!

Hall of Shame

Adding to our Pinoy collection of dubious achievements – high ranking in corruption and extra-judicial killings and bottom of the heap in science and math education – are drugs, alcohol and tobacco addiction.

In 1994, in terms of tobacco consumption of manufactured cigarettes, the Philippines ranked 15^th with some 85.36 billion cigarettes among the 25 leading countries. With respect to relative cost of cigarettes, smokers of 20 cigarettes a day spent 17% of their median household income for local cigarettes and 35% for imported brands in1989 (WHO 1997). At today’s prices, the average smoker blows away P100 a day into cigarette smoke.

In the Philippines, the results of the National Smoking Prevalence Survey of the Department of Health in 1995 indicated that 70% of the current and ex-smokers had finished only elementary or high school education, and that majority belong to the low-income levels. The survey results also showed that among 3,244 youths aged seven to 17 years old, 10% of them once smoked while 4% were current smokers, and the mean age of current and ex-smokers was 12 years old (DOH 1995).

The smoking prevalence derived from the Fifth National Nutrition Survey composed of 4,541 individuals aged 20 years and over in 1999 reported a smoking prevalence wherein 33% of adult Filipinos are current smokers while 13% are ex-smokers, that smoking prevalence among children, as derived from small surveys, is about 30% in urban areas with majority of them smoking from the time they were 13 to 15 years old.

According to a 1987 to 1988 survey among population subgroups, 63% of males and 37% of female physicians were smokers. Thirty-eight percent of respondents said they smoked in front of their patients, and only 59% advised patients on the ill effects of smoking (WHO 1997).

In a preliminary estimate made in the Philippines in 1999, approximately P27 billion will be spent of health care, P1 billion for productivity loss due to illness, while P18 billion will arise from productivity loss due premature death or an annual total of P46 billion for those suffering from smoking-related diseases (Dans et al., 1999).

Approaches to Developing National Plans of Action

Among the key strategies, WHO recommended national plans of action for comprehensive tobacco control that relates to legislative action. The list includes tobacco taxes to be used to finance tobacco control measures and to sponsor sports and cultural events; a ban on all forms of tobacco advertising, promotion and, sponsorship; a legal requirement for strong, varied warnings on cigarette packages; restriction of access to tobacco products, including a prohibition on the sale of tobacco products to young people; limitations on the levels of tar and nicotine permitted in manufactured tobacco products; strategies to provide economic alternatives to tobacco agricultural workers (WHO 1998).

While the sincerity of the legislators crafting the bill cannot be faulted, none of them have gone thru the agonizing withdrawal pangs, the anguish of suppression of craving of an ex-smoker. The ex-smoker knows from experience that success in weaning smokers from the tobacco addiction depends almost entirely on the patient’s will power. It takes three, four or more attempts by even determined quitters before success is achieved. One in denial will probably descend to his grave with a few sticks left in his pocket.