3.19 Smoking and accidents

Last updated: May 2020
Suggested citation: Just, J, Bellew, B & Winstanley, MH. 3.19 Smoking, accidents and injuries. In Scollo, MM and Winstanley, MH [editors].  Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from  http://www.tobaccoinaustralia.org.au/chapter-3-health-effects/3-19-smoking-and-accidents

 

This section covers evidence for the link between smoking and two types of accidents—motor vehicle accidents (MVAs), and fires and burns. It also covers studies investigating a link between smoking and physical injuries. For further information about measures to reduce cigarette-caused fires, see Chapter 12, Attachment 12.2 concerning cigarettes manufactured in order to reduce the risk of them causing fires—termed by various researchers/manufacturers/regulators as ‘reduced fire risk cigarettes’, ‘fire standard compliant and (in Australian regulations) ‘reduced ignition propensity cigarettes’. Fires and burns linked to e-cigarette use are covered in Section 18B.4.

3.19.1 Smoking and motor vehicle accidents (MVAs)

Smoking has been identified as a risk factor for motor vehicle accidents (MVAs) in multiple international studies. Survey data from Canada found that 8.6% of current smokers self-reported being involved in an MVA in the past year compared to 6.5% of non-smokers. When adjusted for potential confounders (including alcohol), current smokers had a small increase in the odds of being involved in an MVA in the previous year compared with non-smokers (OR 1.27, 95%CI 1.06-1.53).1

Similarly, a small study conducted among Italian adolescents compared those who had not experienced any MVAs with those having one or more crash; it reported that the latter were more likely to be tobacco users and the adjusted analyses found that tobacco use was independently predictive of a motor vehicle accident (OR 3.2, p< 0.0001).2 Other Italian research has estimated that about 7% of car injuries in that country may involve a person who smokes while driving.3  

In North American research among teenagers and young adults, being a current smoker was associated with having been in a crash.4 In an Iranian study, being a waterpipe and/or cigarette smoker was found to predict the number of traffic crashes in an adjusted analysis.5

Australian reviews have also concluded that smoking while driving increases the risk of having a motor vehicle crash.6, 7

Several mechanisms have been proposed to explain the association between smoking and MVAs:1

  • Physiological or neurological impairment, such as that caused by mild carbon monoxide poisoning
  • Presence of tobacco-related medical conditions
  • Distractibility, as a result of smoking behaviours and use of smoking paraphernalia while driving. A study using video analysis of people driving while smoking suggests an average of measured driving distraction time to be about 12 seconds, or enough to cover a distance of 160 m at a speed of 50 km/h. The authors suggested that distraction of drivers through smoking may be greater than distraction caused by mobile phone use and that it constitutes a remarkable risk for road safety.8
  • Presence of an unknown confounding factor, such as a personality or behavioural factor that may be linked to both smoking and collision risk.  

Smokers may be also at increased risk of death from MVAs. A recent Japanese study of over 97,000 adults examined traffic accidents involving not only cars but also bicycles, motor bikes and other vehicles. After adjusting for confounders (age and alcohol intake), results suggested that compared to male non-smokers, male current smokers of ≥20 cigarettes per day had an increased risk of traffic accident death (HR 1.54, 95%CI 0.99-2.39). This result closely approached statistical significance. The same study, however, did not find evidence of an increased risk for female smokers or males smokers of <20 cigarettes per day.9

 

3.19.2 Fires and burns caused by tobacco use

Smokers engage in behaviours such as smoking in bed and leaving lit cigarettes unattended that may place them at an increased risk of tobacco-caused fires and burns.

According to the US National Fire Protection Association, smoking was responsible for about 18,100 of residential fires annually between 2012 and 2016. It was the cause of 5% of such fires in the US in that time period. These fires resulted in an average of 1,130 injuries and 590 deaths annually—about 10% of total injuries from fires and 23% of deaths due to fires.10 Smoking was the leading cause of residential fire deaths in the US between 2012 and 2016.10 One US study of furniture fires found that those caused by smoking (as opposed to open flames) were linked with over three times higher odds of death (OR 3.4, 95%CI 1.3-10.9).11

There is a growing trend for tobacco related residential fires to start outside, such as on a balcony or porch. In the US between 2012 and 2016, 18% of tobacco-related fires began from an exterior balcony or unenclosed porch, compared to 1%  between 1980 and 1984.10 This trend likely mirrors growing awareness of the dangers of secondhand smoke and the desire to avoid exposing others inside the home. Interestingly however, the majority of residential fire deaths caused by tobacco use still start in the living room or bedroom.10

In Australia between 2003 and 2017, there were 900 deaths due to preventable residential fires; the most common causes of death were smoke inhalation and burns. For one-third of these fires, the cause was unknown. Of those with known causes, over a quarter of deaths were caused by smoking related materials (around one third started in bed).12 A recent report estimated the total annual cost of smoking-related fire damage in Australia to be $81 million.13

There is evidence that reductions in smoking prevalence and increases in cigarette prices are associated with fewer fires.14, 15

The role of smoking-related materials in causing fires has led to demands for tobacco manufacturers to introduce ‘reduced ignition propensity’ (RIP) cigarettes, which only burn while being actively inhaled upon, as opposed to when they are left idling between puffs, or after they have been discarded.16 Research into the ignition propensity of cigarettes continues to grow.16-31 Among the research results are the important findings that RIP cigarettes do not adversely impact public perceptions about the need for safety,17 appear to reduce consumption although resulting in small increases in smoker exposure to the compound phenanthrene,19 may have little change in the carcinogenic aspects of particulate matter28 and tend to reduce risk behaviours such as leaving a cigarette burning unattended and smoking in bed.20

In the US since 2004, ‘fires standard compliant’ (FSC) cigarettes have been introduced in all states. The wrapping paper of FSC cigarettes includes bands that are regularly spaced. At each band, air flow diminishes, making it more likely that the cigarette will self-extinguish.32 Coinciding with their introduction, there was a 30% reduction in fatalities caused by smoking-related fires between 2003 and 2011. A 2017 modelling study examined the impact of FSC cigarettes on prevalence and severity of residential fires that involved furniture upholstery. The number of these types of fires was reduced by 45% and there was a 23% reduction in fatalities.32

Since 2010, all cigarettes manufactured in or imported into Australia must comply with standards intended to reduce the ignition propensity of cigarettes.33

For further discussion about regulation of tobacco products, see Chapter 12.

Case studies have highlighted the possible fire risks associated with smoking in long-term care settings such as nursing homes,34, 35 and in relation to the usage of certain highly flammable products such as liquid petroleum gas (LPG),36 or automatic air-fresheners.37 In-car cigarette lighters have also been reported as a cause of burn injuries.38

Smoking while using home oxygen therapy (HOT) has also been identified as a major fire risk. HOT is indicated for hypoxaemia (low oxygen levels in the blood) in the context of lung diseases such as chronic obstructive pulmonary disease, congestive heart failure and interstitial lung diseases.39, 40 Smoking while using home oxygen or around home oxygen equipment is dangerous as the oxygen is an accelerant that can result in burns and inhalational injuries, which in some cases can result in death. It has been estimated that between 10% to 50% of patients using home oxygen continue smoking.41 Injuries sustained from smoking while on HOT include facial burns, third degree burns, and swelling of the oropharynx.41 A 2015 review of data from the American Burn Association’s National Burn Repository found that of all HOT-related burns, smoking was the main cause in 83% of cases.40 The review also found that compared to other burns patients (not caused by HOT), those using HOT were more likely to develop pneumonia, require mechanical ventilation, and experience respiratory failure. Likelihood of mortality was also doubled (9% vs 4%, P < .001).40 A retrospective review of HOT patients who smoked and were admitted to a burns unit over six years found that 51% required intubation, and 14.5% died. Interestingly, only 13% had received smoking cessation counselling before their injury.42 The 2015 Thoracic Society of Australia & New Zealand’s clinical practice guideline Adult Domiciliary Oxygen Therapy identifies smoking as a contraindication to HOT: “Oxygen therapy is not indicated for patients who continue to smoke cigarettes because of the increased fire risk and the probability that the poorer prognosis conferred by smoking will offset treatment benefit.”43  

3.19.3 Smoking and other physical injuries

Smokers are also more likely to suffer from injuries, including fatal injuries. 44-47

Possible reasons for this increased risk fall into categories of direct toxic effects of smoking, smoking-related behaviours such as distraction, and indirect or confounding factors. Toxicity from smoking may include the effects on physical performance (such as strength, agility, balance and speed) and impaired recovery from physical trauma (such as post-operative complications and wound, ligament and bone healing delay).46, 48 Smoking is associated with many factors that might increase accidents such as alcohol and drug use, poverty and poor health care, as well as higher risk-taking activity.47, 49

A 2017 meta-analysis examined the relationship between smoking and lower limb overuse injuries in military personnel. Compared with non-smokers, smokers had a 31% increased risk of injury (RR 1.31, 95%CI 1.26-1.36). This association remained significant when adjusted for sex.50

A subsequent 2019 study of 2000 US Army recruits sought to identify the combined impact of smoking and physical fitness levels on injury risk (recognising that both are independent risk factors for injury). ‘Smokers’ were classified as those who had smoked at least 100 cigarettes in their life, and at least one cigarette in the prior 30 days. Fitness levels were ascertained from Army Physical Fitness Test (APFT) data. Smokers, compared with non-smokers, were 20-30% more likely to suffer an injury and although higher fitness levels protected against injury in non-smokers, this protective effect was not evident in smokers.51

Using data from a cross-sectional national survey in Korea, another study investigated the link between smoking and unintentional injuries in adults (categorised into either collisions, stabbings, burns, poisonings, traffic injuries, animal bites, falls and other). The study included data from over 200,000 people and adjusted for demographic, socioeconomic status and lifestyle and health factors. Compared with non-smokers, former smokers had a nearly 20% higher prevalence of unintentional injuries compared to non-smokers and the prevalence was even higher in daily smokers (which increased with number of cigarettes smoked per day, indicating a dose-response relationship).52

A meta-analysis of randomised, controlled trials examined whether smoking cessation prevents excessive injury burden. Intervention (cessation) was associated with pooled estimated injury risk reduction of 35% within the trials (RR 0.65; 95% CI, 0.36–1.19) and of 32% (RR 0.68; 95% CI, 0.43–1.09), however the failure of these analyses to reach statistical significance highlights the need for more research to better test this hypothesis.53


Relevant news and research

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References

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