EXPOSURE TO SECONDHAND SMOKE AND COGNITIVE IMPAIRMENT

INTRODUCTION
Active smoking may be a risk factor for cognitive impairment and

dementia, although it is not clear whether exposure to secondhand smoke is also a risk factor. The health effects of high levels of exposure to secondhand smoke may be close to those of active smoking, including an increased risk of lung cancer, diabetes, cardiovascular disease, hypertension, stroke, and death. As the risks associated with secondhand smoke have become clearer, an increasing number of governments have decided to legislate against smoking in public places. Given the association between exposure to secondhand smoke and risk factors for cognitive impairment such as cardiovascular disease and stroke, it is possible that such exposure may be a preventable risk factor for cognitive impairment. A preliminary analysis of 985 patients (728 women) aged 66-92 years from the Cardiovascular Health Study was carried out (T J Haight et al, 59th annual meeting of the American Academy of Neurology, Boston, 2007) and has been widely reported. Participants who had never smoked, had no history of cardiovascular disease or dementia, and self reported long term exposure to secondhand tobacco smoke (living with a smoker for 30 years or more) were about 30% more likely to develop dementia over a six year period than those who were not exposed (relative hazard 1.3, 95% confidence interval 0.95 to 1.82).

Mild Cognitive Impairment

MCI is an intermediate stage between the

expected cognitive decline of normal aging and the more pronounced decline of dementia. It involves problems with memory, language, thinking and judgment that are greater than typical age-related changes. your memory or mental function has "slipped." And your family and close friends may also notice a change. But generally these changes aren't severe enough to interfere with your day-to-day life and usual activities.

Causes
no single cause of MCI

Current evidence indicates a number of

neurological and medical conditions probably contribute to these symptoms. changes have been identified in autopsy studies of people with MCI :
o Plaques and tangles, which are microscopic protein

clumps characteristic of Alzheimer's disease o Lewy bodies, which are microscopic clumps of another protein associated with Parkinson's disease, dementia with Lewy bodies o Small strokes or reduced blood flow through brain blood vessels

 Brain-imaging studies show that the following

changes:
o Shrinkage of the hippocampus, a brain region

important for memory o Plaques (abnormal clumps of beta-amyloid protein) throughout the brain o Enlargement of the brain's fluid-filled spaces (ventricles) o Reduced use of glucose

Symptoms
Brain changes as you grow older. People notice

gradually increasing forgetfulness as they age. Cognitive issues may go beyond what's expected and indicate possible MCI.
o You forget things more often.
o You forget important events such as appointments

or social engagements.

o You lose your train of thought or the thread of

conversations, books or movies.

o You start to have trouble finding your way around

familiar environments

Diagnose
Many doctors diagnose MCI based on the

following criteria developed by a panel of international experts:

o You have problems with memory, planning,

following instructions or making decisions o your ability has declined from a higher level (confirmed by a family member or a close friend) o Your overall mental function and daily activities are not affected

 Neurological exams. Basic tests that indicate how well

your brain and nervous system are working. Exams may test: Reflexes Eye movements Walking and balance Sense of touch Brain imaging MRI or CT scan to check for evidence of a brain tumor, stroke or bleeding.

 Mental status testing

o Draw a clock face with the hands showing a time

specified by the examiner. o Name today's date and your location. o Copy a design, such as two intersecting pentagons. o Follow a three-step command. o Remember a list of three words spoken to you by the examiner. o Follow a written instruction. o Write down a complete sentence. o Count backward from 100 by sevens

Treatment
No MCI drugs or other treatments are specifically

approved by the Food and Drug Administration (FDA). common conditions besides MCI that make you feel forgetful or less mentally sharp than usual may be treated Conditions that can affect memory include:
o High blood pressure o Depression o Sleep apnea

Secondhand Smoke
Secondhand smoke is composed of sidestream

smoke (the smoke released from the burning end of a cigarette) and exhaled mainstream smoke (the smoke exhaled by the smoker). Old term was ETS, the term secondhand smoke better captures the involuntary nature of the exposure.

 The 2006 Surgeon Generals report uses the term

involuntary because most nonsmokers do not want to breathe tobacco smoke. Secondhand smoke has been designated as a known human carcinogen (cancer-causing agent) by the U.S. Environmental Protection Agency, the National Toxicology Program, and the International Agency for Research on Cancer, and an occupational carcinogen by the National Institute for Occupational Safety and Health.

Toxic and Poisonous

The National Toxicology Program estimates that

at least 250 chemicals in secondhand smoke are known to be toxic or carcinogenic (cancer causing). Secondhand smoke contains poisonous gases and chemicals:
o hydrogen cyanide (used in chemical weapons), o carbon monoxide (found in car exhaust), o butane (used in lighter fluid), o ammonia (used in household cleaners), o toluene (found in paint thinners).

 Some of the toxic metals contained in

secondhand smoke include

o arsenic (used in pesticides), o lead (formerly found in paint), o chromium (used to make steel),

o cadmium (used to make batteries).

 There are more than 50 cancer-causing

chemicals in secondhand smoke :

o Polynuclear aromatic hydrocarbons (PAHs) (such

as Benzo[a]pyrene) o N-Nitrosamines (such as tobacco-specific nitrosamines) o Aromatic amines (such as 4-aminobiphenyl) o Aldehydes (such as formaldehyde) o Miscellaneous organic chemicals (such as benzene and vinyl chloride) and o Inorganic compounds (such as those containing metals like arsenic, beryllium, cadmium, lead, nickel and radioactive polonium-210).

 11 compounds in tobacco smoke have been identified by

the International Agency for Research on Cancer as Group 1 (known human carcinogen) carcinogens.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

2-naphthylamine, 4-aminobiphenyl, benzene, vinyl chloride, ethylene oxide, arsenic, beryllium, nickel compounds, chromium, cadmium and polonium-210

EXPOSURE
At work

In public places
At home In the car

THE CORRELATION
Research Method
o Participants were from the 1998, 1999, and

2001waves of the Health Survey for England who also participated in the 2002 wave of the English Longitudinal Study of Ageing. o The core sample of the English Longitudinal Study of Ageing is limited to adults aged 50 years or more in 2002 and is drawn from the Health Survey for England sample by postcode sector, stratified by health authority and proportion of households in non-manual socioeconomic groups

o Analyses was restricted to the subsample of 5265

non-smoking participants whose salivary cotinine levels were measured. A number of participants were excluded upon particular reasons and remaining 4809 participants formed the sample for the analyses.

Measuring exposure
research used levels of salivary cotinine (ng/ml)

measured in the Health Survey for England as a biomarker for recent exposure to secondhand smoke Cotinine levels were analysed using a gas chromatograph machine with a rapid liquid chromatography technique

Examining Cognitive impairment

Assessed using neuropsychological tests

incorporated in the English Longitudinal Study of Ageing

o attention and processing speed were assessed

using the letter cancellation task from the Medical Research Council National Study of Health and Development. o Time orientation was assessed using questions from the mini-mental state examination. o Immediate and delayed verbal memory were assessed using a 10-word learning task from the Health and Retirement Study.

 Prospective memory was assessed by asking

participants to remember to write their initials in the top left corner of a piece of paper on a clipboard when it was handed to them later in the session , and by asking participants to remind the interviewer to record the time when he or she announced that the cognitive section was finished. Numeracy was assessed using questions relating to simple calculations based on everyday situations The semantic verbal fluency task was taken from the Cambridge cognitive examination (CAMCOG), which examines how many unique

Results
Those with high levels of salivary cotinine (0.8-

13.5 ng/ml) were more likely to be cognitively impaired than those exposed to little or no secondhand smoke (0.0-0.1 ng/ml). Former smokers exposed to the highest levels of secondhand smoke also had increased odds of cognitive impairment although this association was weaker than that observed for never smokers

Possible mechanisms
Exposure to secondhand smoke is associated

with an increased risk of cardiovascular disease, and cardiovascular disease may in turn be associated with an increased risk of cognitive impairment and dementia. study discovered that short term exposure to secondhand smoke adversely affects endothelial function in ways that immediately compromise the cardiovascular system. Dysfunctional endothelial cells contribute to vasoconstriction, atherogenesis, and thrombosis therefore compromise the blood supply to the brain.

 Exposure to secondhand smoke is also a risk

factor for incident stroke, and differences in subclinical cerebrovascular disease may help to explain the noticeable individual differences in cognitive function observed during late adulthood

Conclusion
The results suggest that in a large diverse sample of

non-smoking adults, high levels of cotinine may be associated with increased odds of cognitive impairment. Given the ongoing international policy debate on exposure to secondhand smoke, this is a topic of major public health significance. Prospective nationally representative studies of the association between biomarkers of exposure to secondhand smoke and cognitive decline and dementia are therefore warranted to assess the relation between secondhand smoke and cognitive health with greater precision. In the meantime, current results provide new evidence to suggest that exposure to secondhand smoke may be associated with increased odds of cognitive impairment.

Referrences
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Llewellyn D, Lang I, Langa K, et al. Exposure to secondhand smoke and cognitive impairment in non-smokers: national cross sectional study with cotinine measurement. BMJ 2009;338:b462. The Health Consequences of Involuntary Exposure to Tobacco Smoke. Executive Summary. Surgeon General of the United States. 2006. Retrieved 2009-01-28. Bennett DA, Wilson RS, Schneider JA, Evans DA, Beckett LA, Aggarwal NT, et al. Natural history of mild cognitive impairment in older persons. Neurology 2002;59:198-205. Taylor R, Conway L, Calderwood L, Lessof C. Methodology. In: MarmotM,Banks J,Blundell R, LessofC,Nazroo J, eds. Health,wealth and lifestyles of the older population in England: the 2002 English Longitudinal Study of Ageing. London: Institute of Fiscal Studies, 2003:357-74. NYU medical center. Mild Cognitive Impairment. Available at: http://www.med.nyu.edu/adc/forpatients/cognitiveimpair.html#causes. Accessed on 22nd July 2011. Mayo clinic. Mild cognitive impairment. Available at: http://www.mayoclinic.com/health/mild-cognitive-impairment/DS00553. Accessed on 22nd July 2011. American Cancer Society. Secondhand smoke. Available at: http://www.cancer.org/Cancer/CancerCauses/TobaccoCancer/secondhandsmoke. Accessed on 22nd July 2011.