Protecting Europeans from secondhand smoke: time to actThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. This editorial refers to ‘Secondhand smoke as an acute threat for the cardiovascular system: a change in paradigm’† by T. Raupach et al., on page 386 Raupach et al.1 provide a concise review of the effects of secondhand smoke on the cardiovascular system that complements recent reviews2,3 to synthesize the clinical and experimental evidence that secondhand smoke has rapid and large effects on platelet activation, endothelial function, and myocardial oxygen balance. The effects of secondhand smoke on these important mediators of cardiac function are both direct and indirect, acting through vascular inflammation, and changes in autonomic function. As these changes affect long-term risks, such as developing atheroschlerotic heart disease, most of the effect is immediate (within minutes) and capable of triggering or worsening acute cardiac events. The authors conclude, ‘clinicians need to inform their patients about the risks associated with passive smoking and strongly support the enforcement of smoking bans in all public places.’ This advice comes at an important time for cardiologists and others concerned with heart health in Europe, where the movement for smoke-free air has finally arrived. This movement started at the local level in the USA where, as of November 2005, more than 5700 municipalities (39% of the US population) are covered by a 100% smoke-free provision, restricting smoking in workplaces or public places.4 Fifteen states require 100% smoke-free public places, including California, Delaware, Massachusetts, New York, Rhode Island, and Washington, which cover all workplaces, restaurants, and bars. Ireland made history when it became the first country in Europe (and the first nation in the world) to make all its workplaces, restaurants, and pubs 100% smoke-free on 29 March 2004. Thanks to a strong law, an effective public education campaign about the effects of secondhand smoke, and a serious enforcement effort, Ireland's smoke-free workplace law enjoys over 93% public support, including 80% of smokers.5 The Irish government reports a 97% compliance rate,5 consistent with experience elsewhere.6 Also consistent with the evidence that smoke-free workplaces are associated with a rapid drop in both smoking prevalence and cigarette consumption among continuing smokers,7,8 smoke-free workplaces in Ireland (together with a telephone Quitline) were associated with a 33% reduction in the smoking prevalence. Likewise, consistent with similar results reported in California9 and New York,10 the salivary cotinine (a biomarker of secondhand smoke exposure) levels in Ireland's pub and bar workers dropped by 80%, and workers self-reported being 40% healthier, experiencing fewer respiratory and irritation problems.11 In addition to Ireland, Norway enjoys comprehensive smoke-free protection in all its workplaces, and Italy and Sweden recently implemented national smoke-free laws that include all workplaces, restaurants, and bars. (These do not contain provisions allowing for smoking rooms, which are not effective at protecting workers who must enter those areas.) The Italian association of tobacconists, Assotabaccai, reported a 20% drop in cigarette sales 1 month after Italy's smoke-free law went into effect in January 2005.12 The situation in England is complex. In the face of unwillingness of the Blair Government to act, public health leaders in Liverpool completed the byzantine process required to request a Local Act of Parliament that would allow Liverpool to enact its own local law making workplaces and public places, including restaurants and pubs, smoke-free. As of October 2005, this Act was still pending in Parliament. Meanwhile, the Yorkshire Assembly was discussing plans to make all workplaces smoke-free in the Yorkshire and Humble area, and in March 2005, Guernsey became the first community in the British Isles to pass a 100% smoke-free law in all enclosed workplaces and public places. Scotland, which has been granted autonomy in health matters, is scheduled to implement a law similar to Ireland's in March 2006 and the National Assembly of Wales and Northern Ireland have submitted bills to the UK Government to give them power to pass strong smoke-free protection laws, as well. All this activity in the UK has built pressure on Parliament to act. In 2004, the governing Labour Party released a Public Health White Paper on secondhand smoke,13 that, after repeating tobacco industry rhetoric that the evidence on the dangers of secondhand smoke was still subject to ‘debate’, proposed to continue smoking in bars and pubs that do not prepare and serve food. Although the pub exception seems minor, it is important for two reasons: waiters and waitresses experience the highest levels of secondhand smoke exposure.14 In addition, in the USA, continuing smoking in bars has become central to the tobacco industry's marketing efforts directed at young adults, and one would expect that this marketing strategy will spread to Europe. Germany remains at the opposite end of the spectrum from Ireland, with the tobacco industry so firmly entrenched that the government still considers it a reasonable partner in scientific and educational projects; there is no meaningful smoke-free legislation there. Although the policy debates continue, as Raupach et al.1 demonstrate, the scientific evidence that secondhand smoke has a rapid adverse effect on the cardiovascular system continues to accumulate rapidly. There is already more than enough evidence that smoke-free laws are as popular and work as well in Europe as they do in the USA (and elsewhere). Enacting and implementing such laws will not only improve the quality of the air for Europeans, but will prevent countless heart attacks. Conflict of interest: none declared. doi:10.1093/eurheartj/ehi601