Tobacco Smoke

At a Glance

Tobacco smoke contains chemicals that have been linked to cancer, from both active and passive smoking.

The use of cigarettes has been linked to stroke, coronary heart disease, and many cancers, including lung cancer and breast cancer.

What is tobacco smoke?

Tobacco smoke is a mixture of gases and chemicals that is sent into the air during the burning of tobacco products or from the smoke that is exhaled by a smoker. The smoke that is present in the environment contains multiple chemicals linked to breast cancer, such as benzene and vinyl chloride, both designated as known carcinogens by the International Agency for Research on Cancer or the National Toxicology Program,[1],[2],[3] as well as 1, 3-butadiene, toluene, and nicotine-derived nitrosamine ketone (NNK) that may cause mammary tumors in animals.[4] NNK is a tobacco-specific carcinogen that studies have shown to increase tumor cell proliferation and the transformation of healthy breast epithelial cells into cancer cells.[5],[6],[7]

Passive smoke is the involuntary exposure to somebody else’s tobacco smoke. Passive smokers inhale secondhand smoke from the exhaled smoke of active smokers, and also from the smoke that emerges from smoldering tobacco. Of increasing concern are exposures to third hand smoke, that is, contamination from active smoking that remains in indoor environments long after first and second hand smoke has been released into the air. Third hand smoke is found in in many places, including carpets, furniture, blankets, toys, and even on walls. Over time, as the chemicals from second hand smoke break down, the concentrations of NNK rise and surpass levels found in both active and second-hand smoke residues.[8]

What evidence links active and passive smoking to breast cancer?

Cigarette smoking causes more than 480,000 deaths each year in the United States alone.[9] Tobacco smoke contains chemicals that have been linked to breast and other cancers.[10]

  • The California Teachers Study, one of the largest studies to follow participants over time, found an increased risk of breast cancer among smokers. More specifically, the study revealed a heightened risk for those who began smoking during adolescence, those who had smoked for at least 5 years prior to their first full-term pregnancy, and those who were deemed long-term or heavy smokers.[11] This supported earlier studies that suggested that women who began smoking as adolescents had an increased risk of breast cancer.[12],[13],[14],[15],[16] A recent meta-analysis, however, did not find a relationship between initiation of smoking before a first-time pregnancy and breast cancer risk[17]. More research is needed to explore these inconsistent findings.
  • Multiple studies support increased risk of breast cancer as a result of number of cigarettes smoked, duration of smoking, and age of smoking initiation. Results from the Canadian National Breast Screening Study revealed that smoking for a long period of time and smoking many cigarettes per day were both associated with increased rates of breast cancer.[18] The Nurses’ Health Study and the Women’s Health Initiative Study both indicated similar results, suggesting longer duration of smoking, greater quantities of cigarettes smoked, and younger age when starting to smoke were all positively linked to higher incidence rates of breast cancer.[19],[20]
  • Researchers from the National Cancer Center in Japan reported an increased risk of breast cancer in pre-menopausal women for both active and passive smoking.[21] Research, however, has provided mixed data on the impact passive smoking has on breast cancer risk. The California Teachers Study, for example, revealed no apparent relationship with passive smoking and increased breast cancer risk,[22] while other studies found a positive association between regular exposure to passive smoke and breast cancer risk.[23],[24],[25] The Women’s Health Initiative found that passive smoke exposure lasting more than 10 years in childhood, 20 or more years for adults at home, and 10 years for adults at work was linked to increased risk of breast cancer.[26]
  • While there is currently no direct research on exposures to third-hand smoke and breast cancer outcomes, the fact that NNK levels are highest in third-hand smoke leads scientists to hypothesize that these environmental exposures may well be associated with increased risk for developing NNK sensitive diseases, including perhaps breast cancer.[27]

What about effects of exposures to active and passive smoking in women who have been diagnosed with breast cancer?

  • In a study of almost 5,000 women diagnosed with breast cancer, smoking at the time of diagnosis was associated with an increased risk of recurrence as compare with women who were never smokers. Several other studies support these findings. The results were strongest for women who were heavy smokers at the time of diagnosis.[28],[29]
  • A series of comprehensive reviews have shown that women who are active smokers at the time of diagnosis with breast cancer are significantly more likely to die in the 5-10 years following diagnosis than are women who were never smokers. Much of this difference is covered by increased risk for dying from respiratory disorders and lung cancer, but there was also an increase in smokers dying from breast cancer during the post-diagnosis follow-up periods.[30],[31],[32]
  • Continuing to smoke after diagnosis of breast cancer is associated with an increase in breast cancer specific mortality. Importantly, those women who stopped smoking after their diagnosis (compared to those that did not stop) were significantly less likely to die of either breast cancer or other cancers in the 6 years following their diagnoses.[33]
  • Post-menopausal breast cancer patients with either luminal A or triple negative forms of breast cancer are particularly susceptible to the increases in mortality – both from breast cancer and from other diseases – as a consequence of smoking.[34]
  • Continued active smoking at the time of breast reconstruction surgery following a diagnosis of breast cancer led to a more that 2-fold increase in surgical complications.[35]

Who is most likely to be exposed to tobacco smoke?

Those exposed include tobacco smokers, whether they use cigarettes, pipes, or vaping devices, and non-smokers around them who inhale air polluted with tobacco smoke. Current evidence suggests that both active and secondhand exposure can increase breast cancer risk, even though women who are exposed to secondhand smoke receive a much lower dose of carcinogens than do active smokers.[36],[37]

The Women’s Health Study indicated that 88 percent of people who have never smoked were exposed to passive smoking in their lifetime,[38] so most people will be exposed to tobacco smoke during their lifetime.

While everyone is vulnerable to exposures from third-hand smoke, children – especially toddlers—are especially vulnerable to both exposures to, and effects of, third hand smoke. For example, toddlers are more likely to roll around in contaminated carpets or to inhale dust particles containing NNK.  During these critical times of development, these chemicals may have profound effects on developing systems[39], including breast tissue.

Who is most vulnerable to the health effects?

Overall, research suggests earlier exposures to tobacco smoke are of greater concern.

  • Some studies indicate smoking before a first full-term pregnancy may increase the risk of a later diagnosis of breast cancer.[40],[41]
  • Smoking during adolescence has been found to be associated with increased breast cancer risk.[42],[43],[44],[45],[46]
  • Studies also suggest increased risk of breast cancer for pre-menopausal women.[47]
  • Individuals who have smoked for a long time or have smoked heavily seemed to have higher risks for breast cancer.[[48]

What are the top tips to avoid exposure to tobacco smoke?

  • Stop smoking. Avoid cigarettes and other tobacco products.
  • Avoid secondhand smoke as much as possible.
  • Avoid restaurants, hotels, etc. that do not maintain strict no-smoking policies.

What about smoking marijuana or using smokeless tobacco?

There is no comprehensive research on specific links between alternative uses of tobacco or smoking marijuana on risk of developing breast cancer although these behaviors expose people to many of the same toxic chemicals found in first-, second- and third hand smoke derived from use of tobacco cigarettes.

  • Although marijuana use may be an important therapeutic intervention to address the symptoms of treatment for breast cancer,[49],[50]smoking marijuana exposes people to many of the same contaminants found in cigarette smoke, especially PAHs. Unlike cigarettes, most marijuana formulations do not contain nicotine.
  • Use of snuff or chewing tobacco leads to a significant increase in NNK in the dust from homes of smokeless tobacco users, thereby exposing users and others in the vicinity to the toxic effects of this carcinogenic chemical that has been linked to increased breast cancer.[51]
  • E-cig use, or vaping, results in the exposures to high levels of nicotine which, in turn, is metabolized to NNK. Although no studies have examined association of e-cig second hand vapors and breast cancer risk, one study has shown similar effects on brain activity of second hand tobacco smoke and second hand e-cig vapors.[52] Another concern with vaping is the use of undisclosed flavorings, which may have their own health effects, and also make the products attractive to teens and young adults[53].

Additional Resources

 

Updated 2019 

[1]IARC: International Agency for Research on Cancer (1987):  http://www.inchem.org/documents/iarc/suppl7/benzene.html

[2] National Toxicology Program- U.S. Department of Health and Human Services (13th edition). Vinyl haldies. http://ntp.niehs.nih.gov/ntp/roc/content/profiles/benzene.pdf Retrieved June, 2016.

[3] National Toxicology Program- U.S. Department of Health and Human Services (13th edition). Vinyl haldies. http://ntp.niehs.nih.gov/ntp/roc/content/profiles/vinylhalides.pdf Retrieved June, 2016.

[4] Chen, Z., Liu, C., Chen, F., Li, S., Liang, Q., & Liu, L. (2006). Effects of tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) on the activation of ERK1/2 MAP kinases and the proliferation of human mammary epithelial cells. Environmental Toxicology and Pharmacology, 22(3), 283-291. doi:10.1016/j.etap.2006.04.001

[5] Mei, J., Hu, H., McEntee, M., Plummer (3rd), H., Song, P., & Wang, H. (2003). Transformation of non-cancerous human breast epithelial cell line MCF10A by the tobacco-specific carcinogen NNK. Breast Cancer Res Treat, 79, 95–105.

[6] Chen, Z., An, Y., Wang, Z., Zhang, B., & Liu, L. (2007). Tobacco-specific carcinogen 4-(methylnitrosoamino)-1-(3-pyridyl)-1-butanone (NNK) activating ERK1/2 MAP kinases and stimulating proliferation of human mammary epithelial cells. Chem Res Chin Univ, 23, 76–80

[7] Siriwardhana, N., Choudhary, S., & Wang, H. (2008). Precancerous model of human breast epithelial cells induced by NNK for prevention. Breast Cancer Res Treat, 109, 427–441.

[8] Jacob P, Benowitz NL, Destaillats H, Gundel L, Hang B, Martins-Green M, et al. Thirdhand smoke: New evidence, challenges, and future directions. Chem Res Toxicol. 2017;30(1):270–94.

[9] US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. 2014;17.

[10] OEHHA- Office of Environmental Health Hazard Assessment (2005): http://oehha.ca.gov/media/downloads/air/report/app32005.pdf Retrieved June, 2016.

[11] Reynolds, P., Hurley, S., Goldberg, D., Anton-Culver, H., Bernstein, L., Deapen, D., … Ziogas, A. (2004). Active smoking, household passive smoking, and breast cancer: Evidence from the California Teachers Study. J Natl Cancer Inst, 96, 29-37.

[12] Band PR, Le ND, Fang R, Deschamps M. Carcinogenic and endocrine disrupting effects of cigarette smoke and risk of breast cancer. The Lancet. 2002 Oct 5;360(9339):1044-9.

[13] Calle, E., Miracle-McMahill, H., Thun, M., & Heath, C. (1994). Cigarette smoking and risk of fatal breast cancer. Am J Epidemiol, 139, 1001–1007.

[14] Gram, I., Braaten, T., Terry, P., Sasco, A., Adami, H., Lund, E., & Weiderpass, E. (2005). Breast cancer among women who started smoking as teenagers. Cancer Epidemiol Biomarkers Prev, 14, 61–66.

[15] Johnson KC, Hu J, Mao Y (2000). Passive and active smoking and breast cancer risk in Canada, 1994-1997, The Canadian Cancer Registries Epidemiology Research Group. Cancer Causes Control, 11:211-221.

[16] Marcus, P., Newman, B., Millikan, R., Moorman, P., Baird, D., & Qagish, B. (2000). The associations of adolescent cigarette smoking, alcoholic beverage consumption, environmental tobacco smoke, and ionizing radiation with subsequent breast cancer risk. Cancer Causes Control, 11, 271–278.

[17] DeRoo, LA., Cummings, P., Mueller, BA., (2011). Smoking before the first term pregnancy and the risk of breast cancer: a meta-analysis. AM J Epidemiol, 174, 390-402.

[18] Cui, Y., Miller, A., & Rohan, T. (2006). Cigarette smoking and breast cancer risk: update of a prospective cohort study. Breast Cancer Res Treat, 100, 293.

[19] Xue, F., Willett, W. C., Rosner, B. A., Hankinson, S. E., & Michels, K. B. (2011). Cigarette smoking and the incidence of breast cancer. Arch Inter Med, 171(2), 125–133.

[20] Luo, J., Margolis, K.L., Wactawski-Wende, J. (2011). Association of active and passive smoking with risk of breast cancer among postmenopausal women: a prospective cohort study. BMJ 2011, 342.

[21] Hanaoka, T., Yamamoto, S., Sobue, T., Sasaki, S., & Tsugane, S. (2005). Active and passive smoking and breast cancer risk in middle-aged Japanese women. Int J Cancer, 114, 317–322.

[22] Reynolds, P., Hurley, S., Goldberg, D., Anton-Culver, H., Bernstein, L., Deapen, D., … Ziogas, A. (2004). Active smoking, household passive smoking, and breast cancer: Evidence from the California Teachers Study. J Natl Cancer Inst, 96, 29–37.

[23] Johnson KC, Hu J, Mao Y (2000). Passive and active smoking and breast cancer risk in Canada, 1994-1997, The Canadian Cancer Registries Epidemiology Research Group. Cancer Causes Control, 11:211-221.

[24] Johnson KC, Miller AB, Collishaw NE, Palmer JR, Hammond SK, Salmon AG, Cantor KP, Miller MD, Boyd NF, Millar J, Turcotte F. Active smoking and secondhand smoke increase breast cancer risk: the report of the Canadian Expert Panel on Tobacco Smoke and Breast Cancer Risk (2009). Tobacco control. 2010 Dec 8:tc-2010.

[25] Morabia, A., Bernstein, M., Heritier, S., & Khatchatrian, N. (1996). Relation of breast cancer to active and passive exposure to tobacco smoke. Am J Epidemiol, 143, 918–928.

[26] Luo, J., Margolis, K.L., Wactawski-Wende, J. (2011). Association of active and passive smoking with risk of breast cancer among postmenopausal women: a prospective cohort study. BMJ 2011, 342.

[27]Jacob P, Benowitz NL, Destaillats H, Gundel L, Hang B, Martins-Green M, et al. Thirdhand smoke: New evidence, challenges, and future directions. Chem Res Toxicol. 2017;30(1):270–94.

[28] Lafourcade A, His M, Baglietto L, Boutron-Ruault M-C, Dossus L, Rondeau V. Factors associated with breast cancer recurrences or mortality and dynamic prediction of death using history of cancer recurrences: The French E3N cohort. BMC Cancer. 2018;18(1).

[29] Nechuta S, Chen WY, Cai H, Poole EM, Kwan ML, Flatt SW, et al. A pooled analysis of post-diagnosis lifestyle factors in association with late estrogen-receptor-positive breast cancer prognosis. International Journal of Cancer. 2016;138(9):2088–97.

[30]specific survival: New findings and systematic review with meta-analysis. Breast Cancer Res. 2014;16(2).

[31] Braithwaite D, Izano M, Moore DH, Kwan ML, Tammemagi MC, Hiatt RA, et al. Smoking and survival after breast cancer diagnosis: A prospective observational study and systematic review. Breast Cancer Research and Treatment. 2012;136(2):521–33.

[32] Nechuta S, Chen WY, Cai H, Poole EM, Kwan ML, Flatt SW, et al. A pooled analysis of post-diagnosis lifestyle factors in association with late estrogen-receptor-positive breast cancer prognosis. International Journal of Cancer. 2016;138(9):2088–97.

[33] Passarelli MN, Newcomb PA, Hampton JM, Trentham-Dietz A, Titus LJ, Egan KM, et al. Cigarette smoking before and after breast cancer diagnosis: Mortality from breast cancer and smoking-related diseases. Journal of Clinical Oncology. 2016;34(12):1315–22.

[34] Seibold P, Vrieling A, Heinz J, Obi N, Sinn H-P, Flesch-Janys D, et al. Pre-diagnostic smoking behaviour and poorer prognosis in a German breast cancer patient cohort – differential effects by tumour subtype, NAT2 status, BMI and alcohol intake. Cancer Epidemiol. 2014;38(4):419–26.

[35]Wengler CA, Valente SA, Al-Hilli Z, Woody NM, Muntean JH, Abraham J, et al. Determinants of short and long term outcomes in patients undergoing immediate breast reconstruction following neoadjuvant chemotherapy. J Surg Oncol. 2017;116(7):797–802.

[36] Ambrosone, C., Freudenheim, J., Graham, S., Marshall, J., Vena, J., Brasure, J., … Shields, P. (1996). Cigarette smoking, N-acetyltransferase 2 polymorphisms, and breast cancer risk. J Am Med Assoc, 276, 1494–1501.

[37] Morabia, A., Bernstein, M., Heritier, S., & Khatchatrian, N. (1996). Relation of breast cancer to active and passive exposure to tobacco smoke. Am J Epidemiol, 143, 918–928.

[38] Luo, J., Margolis, K.L., Wactawski-Wende, J. (2011). Association of active and passive smoking with risk of breast cancer among postmenopausal women: a prospective cohort study. BMJ 2011, 342.

[39] Jacob P, Benowitz NL, Destaillats H, Gundel L, Hang B, Martins-Green M, et al. Thirdhand smoke: New evidence, challenges, and future directions. Chem Res Toxicol. 2017;30(1):270–94.

[40] Cui, Y., Miller, A., & Rohan, T. (2006). Cigarette smoking and breast cancer risk: update of a prospective cohort study. Breast Cancer Res Treat, 100, 293.

[41] Xue, F., Willett, W. C., Rosner, B. A., Hankinson, S. E., & Michels, K. B. (2011). Cigarette smoking and the incidence of breast cancer. Arch Inter Med, 171(2), 125–133.

42] Band PR, Le ND, Fang R, Deschamps M. Carcinogenic and endocrine disrupting effects of cigarette smoke and risk of breast cancer. The Lancet. 2002 Oct 5;360(9339):1044-9.

[43] Calle, E., Miracle-McMahill, H., Thun, M., & Heath, C. (1994). Cigarette smoking and risk of fatal breast cancer. Am J Epidemiol, 139, 1001–1007.

[44] Gram, I., Braaten, T., Terry, P., Sasco, A., Adami, H., Lund, E., & Weiderpass, E. (2005). Breast cancer among women who started smoking as teenagers. Cancer Epidemiol Biomarkers Prev, 14, 61–66.

[45] Johnson KC, Hu J, Mao Y (2000). Passive and active smoking and breast cancer risk in Canada, 1994-1997, The Canadian Cancer Registries Epidemiology Research Group. Cancer Causes Control, 11:211-221.

[46] Marcus, P., Newman, B., Millikan, R., Moorman, P., Baird, D., & Qagish, B. (2000). The associations of adolescent cigarette smoking, alcoholic beverage consumption, environmental tobacco smoke, and ionizing radiation with subsequent breast cancer risk. Cancer Causes Control, 11, 271–278.

[47] Hanaoka, T., Yamamoto, S., Sobue, T., Sasaki, S., & Tsugane, S. (2005). Active and passive smoking and breast cancer risk in middle-aged Japanese women. Int J Cancer, 114, 317–322.

[48] Reynolds, P., Hurley, S., Goldberg, D., Anton-Culver, H., Bernstein, L., Deapen, D., … Ziogas, A. (2004). Active smoking, household passive smoking, and breast cancer: Evidence from the California Teachers Study. J Natl Cancer Inst, 96, 29–37.

[49] Bar-Lev Schleider L, Mechoulam R, Lederman V, Hilou M, Lencovsky O, Betzalel O, et al. Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. Eur J Intern Med. 2018;49:37–43.

[50]Caffarel MM, Andradas C, Pérez-Gómez E, Guzmán M, Sánchez C. Cannabinoids: A new hope for breast cancer therapy? Cancer Treat Rev. 2012;38(7):911–8.

[51] Whitehead TP, Havel C, Metayer C, Benowitz NL, Jacob P III. Tobacco Alkaloids and Tobacco-Specific Nitrosamines in Dust from Homes of Smokeless Tobacco Users, Active Smokers, and Nontobacco Users. Chem Res Toxicol. 2015;28(5):1007–14.

[52] Ponzoni L, Moretti M, Sala M, Fasoli F, Mucchietto V, Lucini V, et al. Different physiological and behavioural effects of e-cigarette vapour and cigarette smoke in mice. Eur Neuropsychopharmacol. 2015;25(10):1775–86.

[53] Drazen JM, Morrissey S, Campion EW. The Dangerous Flavors of E-Cigarettes. New Eng J Med [Internet]. 2019 Jan 30 [cited 2019 Mar 14]; Available from: https://www.nejm.org/doi/10.1056/NEJMe1900484

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