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Greater Potential for Heart Failure Linked to Secondhand Smoke Exposure


Compared with nonsmokers who did not have recent exposure to secondhand smoke, a 35% greater chance for heart failure was seen among those with recent exposure to the toxic fumes.

Study findings presented ahead of this year’s American College of Cardiology 70th Annual Scientific Session lay out a possible link between exposure to secondhand tobacco smoke—specifically that from cigarettes—and greater risk of heart failure.

Despite previous research bearing out a connection between worsening heart failure and secondhand smoke exposure, gaps remain in the knowledge around the potential to develop heart failure following exposure to these toxic fumes.

“It adds to overwhelming evidence that secondhand smoke is harmful,” said Travis Skipina, MD, Department of Internal Medicine, Wake Forest School of Medicine, and the study’s lead author, in a statement. “[Secondhand smoke] has been associated with stroke and heart attacks, but what really hadn’t been reported before was its association with heart failure, which is a very debilitating and costly disease."

In 2018 alone, according to the CDC, the price tag was $30.7 billion for such heart failure–related costs as services, medicines, and days off from work.

This cross-sectional analysis by Skipina and coauthors found an overall 35% greater risk of nonsmokers developing heart failure among the close to 20% (N = 11,219 reported nonsmokers) of patients reporting secondhand smoke exposure vs those not exposed to tobacco smoke. Accounting for known risk factors of heart failure, such as high cholesterol and comorbid diabetes, did not alter these results.

For the study, secondhand smoke exposure was defined as having a serum cotinine level of at least 1 ng/mL, a level also used by the CDC.

“Serum cotinine is a metabolite of nicotine that is used to measure levels of smoke exposure and usually signifies that someone has been breathing in tobacco smoke in the environment within the last 1 to 2 days (half-life of 18-20 hours),” the authors noted.

Heart failure was defined via physician diagnosis.

The US Third National Health and Nutrition Examination Survey provided the patient data on individuals followed from 1988 through 1994. Most were women and White, at 55.9% and 70.5%, respectively, and their mean (SD) age was 48 (20.5) years.

Additionally, the elevated risk from secondhand smoke was shown to be greater in individuals with a history of myocardial infarction or stroke vs those with no history (P < .001) and among men compared with women (P = .03).

Individuals with comorbid obesity and diabetes also were shown to have a higher risk.

“Males, in general, tend to get [cardiovascular] disease at a younger age,” Skipina said, “and overall, they were younger, so that may be why they were predisposed.”

The cross-sectional nature of the study and its older data mark limitations on these findings. Still, Skipina noted that even lower levels of secondhand smoke exposure are associated with higher risk of heart failure.

“Active and secondhand smoke induces a proinflammatory state, and higher levels of inflammation affect all body tissues, and it can lead to maladaptive changes in the heart structure and damage to the blood vessels,” he concluded.

More research is needed, Skipina stressed, into the connection between secondhand smoke exposure and heart failure for 2 principal reasons: new methods of exposure (eg, vaping) and higher rates of tobacco use seen among lower-income communities and countries, which often have inadequate health care and less stringent health policies.


Skipina T, Upadhya B, Soliman E. Secondhand smoke is associated with prevalent heart failure: the third National Health and Nutrition Examination Survey. To be presented at: American College of Cardiology's 70th Annual Scientific Session; May 15-17, 2021.

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