1! INTERNATIONAL PROGRAMME ON CHEMICAL SAFETY Environmental Health Criteria 211 Health Effects of Interactions between Tobacco Use and Exposure to other Agents oc INTER-ORGANIZATION PROGRAMME FOR THE SOUND MANAGEMENT OF CHEMICALS IOMC A cooperative agreement among UNEP. ILO, FAG. WFIO, UNIDO, UNITAR and OECD THE ENVIRONMENTAL HEALTH CRITERIA SERIES Acetaldehyde (No. 167, 1995) Chlorofluorocarbons, partially halogenated Acetone (No. 207, 1998) (ethane derivatives) (No. 139, 1992) Acetonitrile (No. 154, 1993) (methane derivatives) (No. 126, 1991) Acrolein (No. 127, 1991) Chloroform (No. 163, 1994) Acrylamide (No. 49, 1985) Chlorophenols (No. 93, 1989) Acrylic acid (No. 191, 1997) Chiorothalonil (No. 183, 1996) Acrylonitrile (No. 28, 1983) Chromium (No. 61, 1988) Aged population, principles for evaluating Chrysotile asbestos (No. 203, 1998) the effects of chemicals (No. 144, 1992) Copper (No. 200, 1998) Aldicarb (No. 121, 1991) Cresols (No. 168, 1995) Aldrin and dieldrin (No. 91, 1989) Cyhalothrin (No. 99, 1990) Allethrins (No. 87, 1989) Cypermethrin (No. 82, 1989) Aluminium (No. 194, 1997) Cypermethrin, alpha- (No. 142, 1992) Amitrole (No. 158, 1994) DDT and its derivatives (No. 9, 1979) Ammonia (No. 54, 1986) DDT and its derivatives - Anticoagulant rodenticides (No. 175, 1995) environmental aspects (No. 83, 1989) Arsenic (No. 18, 1981) Deltamethrin (No. 97, 1990) Asbestos and other natural mineral fibres Demeton-S-methyl (No. 197, 1997) (No. 53, 1986) Diaminotoluenes (No. 74, 1987) Assessment of risks to human health Diazinon (No. 198, 1997) from exposure to chemicals, principles 1,2-Dibromoethane (No. 177, 1996) for the (No. 210, 1999) Di-n-butyl phthalate (No. 189, 1997) Barium (No. 107, 1990) 1 ,2-Dichloroethane Benomyl (No. 148, 1993) (No. 62, 1987, 1st edition) Benzene (No. 150, 1993) (No. 176, 1995, 2nd edition) Beryllium (No. 106, 1990) 2,4-Dichlorophenoxyacetic acid Biomarkers and risk assessment: concepts (2,4-D) (No. 29, 1984) and principles (No. 155, 1993) 2,4-Dichlorophenoxyacetic acid - Biotoxins, aquatic (marine and freshwater) environmental aspects (No. 84, 1989) (No. 37, 1984) 1 ,3-Dichloropropene, 1 ,2-dichloropropane Boron (No. 204, 1998) and mixtures (No. 146, 1993) Brominated diphenylethers (No. 162, 1994) Dichlorvos (No. 79, 1988) Butanols - four isomers (No. 65, 1987) Diesel fuel and exhaust emissions Cadmium (No. 134, 1992) (No. 171, 1996) Cadmium - environmental aspects Diethyihexyl phthalate (No. 131, 1992) (No. 135, 1992) Diflubenzuron (No. 184, 1996) Camphechior (No. 45, 1984) Dimethoate (No. 90, 1989) Carbamate pesticides: a general Dimethylformamide (No. 114, 1991) introduction (No. 64, 1986) Dimethyl sulfate (No. 48, 1985) Carbaryl (No. 153, 1994) Diseases of suspected chemical Carbendazim (No. 149, 1993) etiology and their prevention, Carbon disulfide (No. 10, 1979) principles of studies on (No. 72, 1987) Carbon monoxide (No. 13, 1979) Dithiocarbamate pesticides, Carbon tetrachloride (No. 208, 1999) ethylenethiourea, and propylenethiourea: Carcinogens, summary report on the a general introduction (No. 78, 1988) evaluation of short-term in vitro tests Electromagnetic fields (No. 137, 1992) (No. 47, 1985) Endosulfan (No. 40, 1984) Carcinogens, summary report on the Endrin (No. 130, 1992) evaluation of short-term in vivo tests Environmental epidemiology, guidelines on (No. 109, 1990) - studies in (No. 27, 1983) Chlordane (No. 34, 1984) Epichlorohydrin (No. 33, 1984) Chiordimeform (No. 199, 1997) Ethylbenzene (No. 186, 1996) Chiordecone (No. 43, 1984) Ethylene oxide (No. 55, 1985) Chlorendic acid and anhydride Extremely low frequency (ELF) fields (No. 185, 1996) (No. 36, 1984) Chlorinated paraftins (No. 181, 1996) Fenitrothion (No. 133, 1992) Chlorine and hydrogen chloride Fenvalerate (No. 95, 1990) (No. 21, 1982) Flame retardants: a general introduction Chloroalkyl ethers, selected (No. 201, 1998) (No. 192, 1997) Chlorobenzenes other than Flame retardants: tris(chloropropyl) hexachlorobenzene (No. 128, 1991) phosphate and tris(2-chloroethyl) phosphate Chlorofluorocarbons, fully halogenated (No. 209, 1998) (No. 113, 1990) Fluorine and fluorides (No. 36, 1984) continued at end of book This report contains the collective views of an international group of experts and does not necessarily represent the decisions or the stated policy of the United Nations Environment Progrannne, the International Labour Organisation, or the World Health Organization. Environmental Health Criteria 211 HEALTH EFFECTS OF INTERACTIONS BETWEEN TOBACCO USE AND EXPOSURE TO OTHER AGENTS First draft prepared by Dr K. Rothwell, Knaresborough, Yorkshire, United Kingdom Published under the joint sponsorship of the United Nations Environment Programme, the International Labour Organisation, and the World Health Organization, and produced within the framework of the Inter-Organization Programme for the Sound Management of Chei. ..,- 1 £• World Health Organization Geneva, 1999 The International Programme on Chemical Safety (IIPCS), established in 1980, is a joint venture of the United Nations Environrrient Programme (UNEP), the International Labour Organisation (ILO), and the World Health Organization (WHO). The overall objectives of the IPCS are to establish the scientific basis for assessment of the risk to human health and the environment from exposure to chemicals, through international peer review processes, as a prerequisite for the promotion of chemical safety, and to provide technical assistance in strengthening national capacities for the sound management of chemicals. The Inter-Organization Programme for the Sound Management of Chemicals (IOMC) was established in 1995 by UNEP, ILO, the Food and Agriculture Organization of the United Nations, WHO, the United Nations Industrial Development Organization, the United Nations Institute for Training and Research, and the Organisation for Economic Co-operation and Development (Participating Organizations), following recommendations made by the 1992 UN Conference on Environment and Development to strengthen cooperation and increase coordination in the field of chemical safety. The purpose of the IOMC is to promote coordination of the policies and activities pursued by the Participating Organizations, jointly or separately, to achieve the sound management of chemicals in relation to human health and the environment. WHO Library Cataloguing-in-Publication Data Health effects of interactions between tobacco use and exposure to other agents. (Environmental health criteria 211) I Smoking - adverse effects 2.Tobacco smoke pollution 3.Drug interactions 4 Environmental exposure 5 Occupational exposure 6.Risk factors I.International Programme on Chemical Safety II.Series ISBN 92 4 157211 6 (NLM Classification: QV 137) ISSN 0250-863X The World Health Organization welcomes requests for pennission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. ©World Health Organization 1999 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city, or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. Printed in Finland 99112503 - Vammala - 5000 CONTENTS HEALTH EFFECTS OF INTERACTIONS BETWEEN TOBACCO USE AND EXPOSURE TO OTHER AGENTS PREAMBLE ix ABBREVIATIONS xx 1. OVERVIEW 1 1.1 Introduction 1 1.2 Examples of combined effects of tobacco smoking and other exposures 2 1.3 Composition of tobacco leaf and tobacco smoke 3 1.4 Mainstream tobacco smoke 3 1.5 Sidestream tobacco smoke 5 1.6 Effects of ways of cigarette smoking on smoke toxicity 5 1.7 Summary of conclusions and recommendations 6 2. EXPOSURE TO TOBACCO PRODUCTS AND HEALTH RISKS FROM TOBACCO USE 7 2.1 Tobacco andits uses 7 2.1.1 Introduction 7 2.1.2 Tobacco smoking 8 2.1.3. Tobacco chewing and snuff 16 2.2 Responses to mainstream smoke 16 2.2.1 Acute responses 17 2.2.1.1 Acute bronchitis 17 2.2.1.2 Asthma 17 2.2.2 Chronic responses 18 2.2.2.1 Chronic obstructive lung diseases (COLD) 18 2.2.2.2 Chronic bronchitis 19 2.2.2.3 Small airways disease 19 2.2.2.4 Emphysema 19 Yn EHC 211: Tobacco Use and Exposure to OtherAgents 2.2.2.5 Pulmonary fibrosis 20 2.2.2.6 Effects on the immune system 21 2.2.3 Cancer 21 2.2.4 Cardiovascular effects 24 2.2.5 Smokmg and occupational accidents, injuries and absenteeism 26 2.3 Health risks from smokeless tobacco use 26 2.3.1 Introduction 26 2.3.2 Cancer 26 2.3.3 Cardiovascular disease 28 3. EFFECTS ON HEALTH OF TOBACCO USE AND EXPOSURE TO OTHER CHEMICALS 29 3.1 Introduction 29 3.1.1 Interaction 29 3.12 Measuring interaction 29 3.1.3 Effects of tobacco smoking on lung deposition