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One Cigarette A Day Won't Keep Doctor Away

25 January 2018 | Updated 01 January 1970

Only total cessation of smoking will protect people and populations from tobacco’s toxic legacy says the BMJ, with just on cigarette a day seriously elevating cardiovascular risk.

Any assumption that smoking less protects against heart disease or stroke has been dispelled this week in the BMJ. In a large meta-analysis of observational studies, it has been show the unexpected extent to which smoking even one cigarette a day is associated with major cardiovascular risk.

The results are compelling. Smoking one cigarette a day was associated with a 48% to 74%  increase in the risk of coronary heart disease (CHD) in men, a 57% to 119% increase in CHD risk for women and a roughly 30% increase in the risk of stroke for both men and women.

One cigarette a day accounted for fully half of the excess CHD risk associated with smoking 20 a day in men and for one third of the risk in women. For stroke, one cigarette accounted for roughly one third of the risk associated with smoking 20 a day.

The meta-analysis is impressive, based on 141 prospective cohort studies from 21 countries and regions that followed 5.6 million individuals for CHD and 7.3 million for stroke. It includes 110 000 new cases of CHD and 135 000 cases of stroke. Risks associated with one, five, and 20 cigarettes a day were modelled in each study, for CHD and stroke, controlling for at least age and sex, and statistically summarised across all studies using random effects meta-analysis.


More heart deaths than cancer

About 900 million people smoke worldwide. If trends continue, an estimated 1 billion premature deaths from smoking will occur this century. Cardiovascular disease, not cancer, is the greatest mortality risk for smoking, causing about 48% of smoking related premature deaths.

The substantial risk of CHD associated with 'low' exposure to tobacco smoke first came to light in the 1990s. Despite much lower levels of smoke exposure than active smoking, in a seminal meta-analysis in the BMJ, Law and colleagues calculated a 30% increase in CHD risk among people who had never smoked but were exposed to second-hand smoke (19 studies) and a 39% increase in CHD risk among smokers smoking one cigarette a day (five studies).

Barnoya and Glantz reported in a literature review in 2005 that: Evidence is rapidly accumulating that the cardiovascular system - platelet and endothelial function, arterial stiffness, atherosclerosis, oxidative stress, inflammation, heart rate variability, energy metabolism, and increased infarct size - is exquisitely sensitive to the toxins in secondhand smoke. The effects of even brief (minutes to hours) passive smoking are often nearly as large (averaging 80% to 90%) as chronic active smoking.


Give 'em up

The high cardiovascular risk associated with very low cigarette use has major public health implications. Firstly, light smoking, occasional smoking and smoking fewer cigarettes all carry substantial risk of cardiovascular disease. Only complete cessation is protective .

Secondly, passive smoking is essentially another form of low dose smoking that carries a substantial cardiovascular risk. Comprehensive smoke-free laws in public places, now common in high resource countries, result in large drops in hospital admissions (about 15%) for cardiac, cerebrovascular and lung disease. It would be prudent for low resource countries to follow suit.

Marijuana and sheesha (hookah) smoke are also of concern because incomplete combustion of organic substances produces many highly toxic chemicals, with similar serious adverse health consequences.


Don't escape with a vape

Thirdly, new tobacco products, such as e-cigarettes and heat-not-burn cigarettes, may carry substantial risk for heart disease and stroke. Although e-cigarettes deliver reduced levels of carcinogens, they still expose users to high levels of ultra fine particles and other toxins that may markedly increase cardiovascular risk. Somewhat lower emissions of many toxic substances from heat-not-burn cigarettes do not make these products safe.

The BMJ says, e-cigarettes and heat-not-burn products should not be promoted for harm reduction on the grounds that they lead people to smoke fewer cigarettes because modest reductions in cigarette consumption are unlikely to have meaningful health benefits and dual use of cigarettes and e-cigarettes may expose smokers to increased total risks.

It is also claimed that e-cigarettes are reducing smoking cessation rates and marketing of supposedly safer tobacco products seems to recruit and addict new generations of young smokers.

The BMJ says regulatory approval of these products should be withheld as society cannot afford to wait several more decades to document the illness, disability and deaths caused by new recreational tobacco and nicotine products.

Picture: The take home message from the BMJ for smokers is that any exposure to cigarette smoke is too much. The message for regulators dealing with newly marketed reduced risk products is that any suggestion of seriously reduced CHD and stroke from using these products is premature

Article written by Cathryn Ellis | Published 25 January 2018


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