Langerhans cell histiocytosis (Ryu et al., 2001), and cryptogenic fibrosing alveolitis (Hubbard et al., 2000).

Other Health Effects of Tobacco Use

Numerous other health effects that may affect military personnel health and readiness are caused by or have been associated with smoking (US Surgeon General, 2004). As mentioned previously, smoking causes duodenal and gastric ulcers, is associated with esophageal reflux symptoms, delays the rate of ulcer healing, and increases the risk of relapse after ulcer treatment. It increases the risk of osteoporosis and causes a reduction in the peak bone mass attained in early adulthood, and it increases the rate of bone loss in later adulthood. Smoking antagonizes the protective effect of estrogen-replacement therapy on the risk of osteoporosis in postmenopausal women. It can cause cataracts and increases the risk of macular degeneration. Smoking reduces the secretion of thyroid hormone and may increase the severity of clinical symptoms of hypothyroidism. It also interacts with a variety of drugs—such as insulin, antihypertensive drugs, a number of psychiatric drugs, and some cancer chemotherapeutic agents—by accelerating drug metabolism or by the pharmacologic interactions of nicotine and other constituents of tobacco with other drugs (US Surgeon General, 2004). Smoking is also associated with poor reproductive outcomes in women, including reduced fertility and babies with low birth weight (US Surgeon General, 2004).

Health Effects of Secondhand Smoke

Exposure to secondhand smoke is a well-established cause of death, illness, and annoyance in nonsmokers (US Surgeon General, 2007). Secondhand smoke contains the same toxic constituents as mainstream smoke, some of which are present in higher concentrations than in mainstream smoke. Some constituents of secondhand smoke persist at high concentrations for many hours after smoking has ceased (Singer et al., 2002, 2003).

In nonsmoking adults, secondhand-smoke exposure is associated with an increased risk of lung cancer and acute myocardial infarction (MI) and a 20–30% excess risk of coronary heart disease (Chen and Boreham, 2002). Meta-analyses showed that secondhand smoke increases the risk of acute MI by 31% (Barnoya and Glantz, 2005) and the risk of lung cancer by up to 20% (IARC, 2004). Several recent studies have found that implementation of smoke-free indoor-air regulations results in a rapid decline in the risk of acute MI and other acute cardiovascular events (Pell et al., 2008). Secondhand smoke also increases the severity of some infectious diseases, such as influenza, and



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