• Research Review
• Journal Summary

Authors: D Yach

Reference: Progress in Cardiovascular Diseases 2010;53:52-54 (open access on ProCor) http://www.procor.org/news/news_show.htm?doc_id=1305731

Summarized by: Joaquin Barnoya, MD, MPH, Contributing Editor, ProCor; Research Assistant, Professor of Surgery, Washington University in St. Louis, Missouri, USA; Director, Research and Education, Unidad de Cirugia Cardiovascular de Guatemala, Guatemala

Summary: This editorial reviews the contribution of the Framingham Heart Study (FHS) to the field of global tobacco control. Little was known about cardiovascular disease (CVD) risk factors when the FHS was designed. However, by the 1950s results from this study had yield a three-fold increase in CVD mortality in heavy smokers compared to nonsmokers. This result was cited by two seminal reports that changed the field of tobacco and CVD risk factors: the 1962 Royal College of Physicians Report and the 1964 US Surgeon General Report (SGR) on "Smoking and Health". For the first time tobacco use was determined to "cause" mortality and this had a major impact on how "causation" was determined for other risk factors. Interestingly enough, the SGR concluded causality with lung cancer in men, but regarding CVD even though there was a higher death rate from coronary artery disease "it is not clear that the association has causal significance". These same conclusions where reached by the Royal College of Physicians Report.

Despite these two reports, tobacco still accounts for a considerable proportion of deaths worldwide. Eighteen percent, 11%, and 4% of all deaths in high-, middle-, and low-income countries can be attributed to tobacco. Secondhand smoke (SHS), an established risk factor for CVD in nonsmokers, was not investigated in the FHS at the time it was designed. However, since 2006 the Surgeon General Report has concluded that SHS is a cause of CVD. Therefore, smoke-free environments have spread as the only solution to SHS exposure and have led to a dramatic decrease in CVD incidence and mortality shortly after they are implemented. Still, most of the world's population does not enjoy the benefits of smoke-free environments (an estimated 43% of children ages 13-15 are still exposed to SHS at home).

The SGR and the Royal College of Physicians Report are not mandated to issue recommendations. In this regard, even though published more than 30 years ago, it was not until 2009 that the US Food and Drug Administration gained authority to regulate tobacco. Regardless, nongovernmental organizations, led by the American Cancer Society, have taken the lead in the fight against tobacco. Interestingly enough, most of this fight has been lead by cancer groups while heart foundations and associations have focused on nutritional causes.

Regarding the World Health Organization (WHO), after years of issuing resolutions they were codified into the WHO Framework Convention on Tobacco Control (FCTC). This is the first public health treaty signed under the WHO. Still, with a treaty to guide tobacco control measures in every country, less than 10% of the world's population is covered by key tobacco control policies.

Comments: Finally, every country should consider developing their version of the Framingham as it is much more difficult for governments to ignore their own data. Fortunately, the National Institutes of Health and the Center for Disease Control and Prevention are now playing a key role in partnering with international researchers so all can benefit from the lessons learned from Framingham.

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