Breast Cancer ebooksclub.org Tobacco or Health Physiological and Social Damages Caused by Tobacco Smoking Second Edition

stage,฀shortly฀before฀the฀development฀of฀breast฀tissue,฀in฀order฀to฀induce฀mitogenic฀changes฀ consistent฀with฀carcinogenesis฀ [246] .฀More฀extensive฀studies฀are฀certainly฀required฀in฀this฀ area฀before฀a฀deinitive฀verdict฀can฀be฀given. Johnson฀and฀Glantz฀compared฀the฀strength฀of฀evidence฀from฀epidemiologic฀studies฀of฀ second฀hand฀smoke฀of฀the฀US฀Surgeon฀General’s฀1986฀conclusion฀that฀secondhand฀smoke฀ caused฀ lung฀ cancer฀ with฀ the฀ California฀ Environmental฀ Protection฀ Agency’s฀ CalEPA฀ similar฀2005฀conclusion฀on฀breast฀cancer฀in฀younger,฀primarily฀premenopausal฀women฀ [247] .฀They฀reviewed฀each฀report฀for฀criteria฀used฀to฀assess฀causality:฀number฀of฀studies,฀ statistically฀signiicant฀increases฀in฀risk,฀and฀pooled฀summary฀risk฀estimates.฀The฀authors฀ showed฀that฀both฀the฀Surgeon฀General฀and฀CalEPA฀used฀updated฀Bradford฀Hill฀criteria฀for฀ assessing฀causality฀and฀found฀that฀the฀evidence฀met฀those฀criteria.฀Six฀of฀13฀lung฀cancer฀ studies฀46฀had฀statistically฀signiicant฀increases฀one฀of฀three฀cohort฀studies.฀Pooled฀ risk฀ estimates฀ for฀ lung฀ cancer฀ for฀ spousal฀ exposure฀ were฀ 1.53฀ for฀ ten฀ combined฀ case-฀ control฀studies฀and฀1.88฀for฀seven฀studies฀with฀dose–response฀results.฀The฀CalEPA฀reported฀ 10฀of฀14฀studies฀71฀had฀statistically฀signiicant฀increases฀in฀breast฀cancer฀risk฀two฀of฀ four฀cohort฀studies.฀Pooled฀relative฀risk฀estimates฀for฀younger,฀primarily฀premenopausal฀ women฀were฀1.68฀95฀CI:฀1.33,฀2.12฀for฀all฀exposed฀women฀and฀2.19฀95฀CI:฀1.68,฀ 2.84฀for฀ive฀studies฀with฀better฀exposure฀assessment.฀It฀was฀concluded฀that฀the฀evidence฀ from฀epidemiologic฀studies฀of฀passive฀smoke฀in฀2005฀for฀breast฀cancer฀in฀younger,฀primar- ily฀premenopausal฀women฀was฀stronger฀than฀for฀lung฀cancer฀in฀1986.

9.10 Psychosocial Changes

Children฀exposed฀to฀ETS฀display฀behavioural฀changes฀that฀can฀be฀linked฀with฀ETS.฀Within฀a฀ family฀ setting,฀ lifestyle฀ habits฀ evolve฀ e.g.฀ smoking,฀ fat฀ consumption,฀ sedentary฀ lifestyle฀ increased฀alcohol฀consumption฀which฀in฀turn฀may฀be฀regarded฀as฀risk฀factors฀for฀the฀children฀ because฀they฀adopt฀these฀lifestyle฀habits฀ [248,฀249] .฀Body฀measurements฀were฀performed฀in฀ a฀study฀of฀804฀children฀aged฀10–12฀years;฀additionally,฀smoking฀behaviour฀and฀dietary฀char- acteristics฀were฀identiied.฀Among฀the฀children฀from฀these฀families,฀19฀of฀boys฀and฀10฀of฀ girls฀were฀already฀smokers.฀Among฀the฀children฀who฀smoked,฀57฀boys฀and฀68฀girls฀ came฀from฀families฀in฀which฀at฀least฀one฀parent฀smoked฀OR,฀2.1;฀CI,฀1.2–3.8.฀In฀the฀longer฀ term,฀however,฀girls฀were฀less฀likely฀to฀adopt฀the฀smoking฀habits฀of฀their฀parents฀OR,฀0.4;฀ CI,฀0.2–0.6.฀Parental฀smoking฀behaviour฀was฀an฀additive฀predictor฀in฀children฀of฀lower฀ physical฀activity฀and฀more฀television฀watching,฀regardless฀of฀which฀parent฀smoked.฀Children’s฀ fat฀intake฀was฀signiicantly฀greater฀if฀either฀parent฀smoked,฀whereas฀children’s฀body฀mass฀ index฀and฀waist-to-hip฀ratio฀were฀signiicantly฀greater฀if฀mothers฀smoked฀ [250] . Overall,฀children฀who฀grow฀up฀in฀“smoker฀households”฀take฀health฀risks฀upon฀them- selves฀ regardless฀ of฀ the฀ risks฀ already฀ present฀ as฀ a฀ result฀ of฀ smoking฀ during฀ pregnancy฀ [251] .฀Parental฀smoking฀is฀formative฀in฀encouraging฀an฀unhealthy฀lifestyle฀in฀children,฀ expressed฀ as฀ a฀ preference฀ for฀ sitting฀ around฀ [96] ,฀ earlier฀ alcohol฀ consumption฀ [252] ,฀ increased฀fat฀intake฀ [252,฀253] ฀or฀an฀accumulation฀of฀these฀unhealthy฀behaviours฀ [254] .฀ The฀smoking฀habits฀of฀the฀children฀also฀correlate฀with฀those฀of฀their฀parents,฀as฀has฀been฀ demonstrated฀in฀several฀studies฀ [255–257] .฀Readers฀are฀referred฀to฀ Chap.฀12 ฀for฀further฀ discussion฀of฀this฀aspect.

9.11 Concluding Remarks

The฀data฀presented฀in฀the฀literature฀permit฀a฀range฀of฀conclusions,฀several฀of฀which฀are฀of฀ major฀importance฀in฀terms฀of฀public฀health฀policy: • ฀ Adult฀ non–smokers฀ exposed฀ to฀ ETS฀ become฀ ill฀ more฀ frequently฀ than฀ non-smokers฀ without฀ETS฀exposure,฀prompting฀the฀conclusion฀that฀smoking฀should฀be฀banned฀in฀the฀ workplace฀and฀in฀public฀buildings. • ฀ Non-smokers฀and฀smokers฀should฀be฀educated฀about฀the฀dangers฀of฀ETS,฀the฀objective฀ being฀to฀reduce฀or฀prevent฀ETS฀in฀their฀own฀homes. • ฀ Any฀study฀of฀the฀medical฀consequences฀of฀smoking฀and฀any฀comparison฀with฀the฀situ- ation฀in฀non-smokers฀must฀always฀consider฀the฀role฀played฀by฀ETS฀because฀this฀factor฀ already฀leads฀to฀health-related฀changes. • ฀ Despite฀ contradictory฀ data,฀ it฀ has฀ now฀ been฀ proved฀ that฀ extensive฀ ETS฀ exposure฀ a฀฀minimum฀of฀20–30฀pack-years฀increases฀the฀risk฀of฀bronchial฀carcinoma฀by฀at฀least฀ 30,฀and฀in฀extreme฀cases฀this฀risk฀may฀be฀increased฀two-฀to฀threefold.฀Ethnic฀differ- ences฀appear฀to฀exist,฀with฀Asian฀populations฀being฀at฀even฀greater฀risk฀than฀those฀in฀ Western฀Europe฀or฀North฀America. • ฀ Female฀ smokers฀ planning฀ to฀ become฀ pregnant฀ or฀ unexpectedly฀ becoming฀ pregnant฀ should฀make฀every฀effort฀to฀stop฀smoking฀either฀before฀pregnancy฀or฀during฀the฀irst฀ weeks฀of฀pregnancy.฀They฀should฀also฀refrain฀from฀smoking฀during฀the฀irst฀years฀after฀ their฀child฀has฀been฀born.฀The฀same฀applies฀for฀fathers฀living฀in฀the฀same฀household. • ฀ The฀mother฀is฀the฀key฀igure฀in฀determining฀a฀healthy฀lifestyle฀for฀the฀family,฀and฀this฀ should฀be฀the฀starting฀point฀increasingly฀for฀health฀education฀programmes฀in฀future. • ฀ Before฀ infants฀ and฀ young฀ children฀ undergo฀ a฀ general฀ anaesthetic,฀ parental฀ smoking฀ status฀should฀always฀be฀ascertained.฀Where฀parents฀are฀smokers,฀the฀risk฀of฀anaesthetic฀ complications฀during฀the฀recovery฀phase฀is฀doubled.฀Urinary฀cotinine฀measurements฀ can฀be฀helpful฀in฀this฀context. • ฀ If฀the฀health฀of฀the฀majority฀is฀not฀to฀be฀further฀endangered฀by฀ETS,฀there฀is฀an฀urgent฀ need฀to฀introduce฀strict฀legislation฀for฀the฀protection฀of฀non-smokers฀Fig.฀ 9.11 . • ฀ The฀general฀population฀should฀also฀be฀kept฀aware฀of฀the฀latest฀findings฀on฀ETS:฀the฀ danger฀ to฀ health฀ must฀ be฀ clearly฀ communicated฀ so฀ that฀ children฀ and฀ adolescents฀ in฀ particular฀are฀protected฀effectively.