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
For recent news items and research on this topic, click here. (Last updated October 2020)
1. Vingilis E, Pederson LL, Seeley J, Ialomiteanu AR, Wickens CM, et al. Is there a link between motor vehicle collisions and being a cigarette smoker in Canada? Analysis of survey data from Ontario from 2002-2014. Traffic Injury Prevention, 2017:0. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29265880
2. Pizza F, Contardi S, Antognini AB, Zagoraiou M, Borrotti M, et al. Sleep quality and motor vehicle crashes in adolescents. Journal of Clinical Sleep Medicine, 2010; 6(1):41-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20191936
3. Iacobelli N, Gallus S, Petridou E, Zuccaro P, Colombo P, et al. Smoking behaviors and perceived risk of injuries in Italy, 2007. Preventive Medicine, 2008; 47(1):123–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18501413
4. Hutchens L, Senserrick TM, Jamieson PE, Romer D, and Winston FK. Teen driver crash risk and associations with smoking and drowsy driving. Accident Analysis and Prevention, 2008; 40(3):869–76. Available from: https://pubmed.ncbi.nlm.nih.gov/18460353/
5. Saadat S and Karbakhsh M. Association of waterpipe smoking and road traffic crashes. BMC Public Health, 2010; 10:639. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20969795
6. Young K, Regan M, and Hammer M. Driver distraction: a review of the literature. Report 206. Clayton, Victoria: Monash University Accident Research Centre, 2003. Available from: https://www.monash.edu/__data/assets/pdf_file/0007/217177/Driver-distraction-a-review-of-the-literature.pdf.
7. Road Safety Committee. Inquiry into Driver Distraction No.209 Session 2003-2006 2006. Available from: https://www.parliament.vic.gov.au/images/stories/committees/rsc/driver_distraction/Distraction_Final_Report1.pdf.
8. Mangiaracina G and Palumbo L. [Smoking while driving and its consequences on road safety]. Annali di Igiene, 2007; 19(3):253-67. Available from: https://pubmed.ncbi.nlm.nih.gov/17658112/
9. Igarashi A, Aida J, Sairenchi T, Tsuboya T, Sugiyama K, et al. Does cigarette smoking increase traffic accident death during 20 years follow-up in Japan? The Ibaraki Prefectural Health Study. Journal of Epidemiology, 2018. Available from: http://www.ncbi.nlm.nih.gov/pubmed/29848905
10. Ahrens M. Home fires started by smoking National Fire Protection Association 2019. Available from: www.nfpa.org/News-and-Research/Data-research-and-tools/US-Fire-Problem.
11. Rodgers KM, Swetschinski LR, Dodson RE, Alpert HR, Fleming JM, et al. Health Toll From Open Flame and Cigarette-Started Fires on Flame-Retardant Furniture in Massachusetts, 2003-2016. American Journal of Public Health, 2019:e1-e7. Available from: www.ncbi.nlm.nih.gov/pubmed/31318595
12. Coates L, Kaandorp G, Harris J, van Leeuwen J, Avci A, et al. Preventable residential fire fatalities: July 2003-June 2017 Bushfire and Natural Hazards CRC 2019. Available from: www.bnhcrc.com.au/publications/biblio/bnh-5807.
13. National Drug Research Institute Curtin University. Identifying the social costs of tobacco use to Australia in 2015/16 Perth, WA 2019 Available from: http://ndri.curtin.edu.au/NDRI/media/documents/publications/T273.pdf.
14. Markowitz S. Where there's smoking, there's fire: the effects of smoking policies on the incidence of fires in the United States. NBER working paper no.1665, Cambridge, Massachusetts: National Bureau of Economic Research 2010. Available from: http://papers.nber.org/papers/w16625.
15. Kegler SR, Dellinger AM, Ballesteros MF, and Tsai J. Decreasing residential fire death rates and the association with the prevalence of adult cigarette smoking - United States, 1999-2015. Journal of Safety Research, 2018; 67:197-201. Available from: www.ncbi.nlm.nih.gov/pubmed/30553424
16. Chapman S and Balmain A. Time to legislate for fire-safe cigarettes in Australia [Editorial]. Medical Journal of Australia, 2004; 181(6):292-3. Available from: http://www.mja.com.au/public/issues/181_06_200904/cha10373_fm.html
17. Seidenberg AB, Rees VW, Alpert HR, O'Connor RJ, Giovino GA, et al. Smokers' self-reported responses to the introduction of reduced ignition propensity (RIP) cigarettes. Tobacco Control, 2012; 21(3):337-40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21752794
18. Seidenberg AB, Rees VW, Alpert HR, O'Connor RJ, and Connolly GN. Ignition strength of 25 international cigarette brands. Tobacco Control, 2011; 20(1):77-80. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20974622
19. O'Connor RJ, Rees VW, Norton KJ, Cummings KM, Connolly GN, et al. Does switching to reduced ignition propensity cigarettes alter smoking behavior or exposure to tobacco smoke constituents? Nicotine &Tobacco Research, 2010; 12(10):1011-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20805292
20. O'Connor RJ, Fix BV, Hammond D, Giovino GA, Hyland A, et al. The impact of reduced ignition propensity cigarette regulation on smoking behaviour in a cohort of Ontario smokers. Injury Prevention, 2010; 16(6):420-2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20643872
21. Cote F, Letourneau C, Mullard G, and Voisine R. Estimation of nicotine and tar yields from human-smoked cigarettes before and after the implementation of the cigarette ignition propensity regulations in Canada. Regulatory Toxicology and Pharmacology, 2011; 61(3 Suppl):S51-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20303374
22. Alpert HR, O'Connor RJ, Spalletta R, and Connolly GN. Recent advances in cigarette ignition propensity research and development. Fire Technology, 2010; 46(2):275-89. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2873202/pdf/nihms122218.pdf
23. O'Connor RJ, Giovino GA, Fix BV, Hyland A, Hammond D, et al. Smokers' reactions to reduced ignition propensity cigarettes. Tobacco Control, 2006; 15(1):45-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16436405
24. Connolly GN, Alpert HR, Rees V, Carpenter C, Wayne GF, et al. Effect of the New York State cigarette fire safety standard on ignition propensity, smoke constituents, and the consumer market. Tobacco Control, 2005; 14(5):321-7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16183983
25. Laugesen M, Duncanson M, Fraser T, McClellan V, Linehan B, et al. Hand rolling cigarette papers as the reference point for regulating cigarette fire safety. Tobacco Control, 2003; 12(4):406-10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14660777
26. Barillo DJ, Brigham PA, Kayden DA, Heck RT, and McManus AT. The fire-safe cigarette: a burn prevention tool. Journal of Burn Care and Rehabilitation, 2000; 21(2):162-4; discussion 4-70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10752750
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28. Brunnemann KD, Hoffmann D, Gairola CG, and Lee BC. Low ignition propensity cigarettes: smoke analysis for carcinogens and testing for mutagenic activity of the smoke particulate matter. Food and Chemical Toxicology, 1994; 32(10):917-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7959447
29. Botkin JR. The fire-safe cigarette. Journal of the American Medical Association, 1988; 260(2):226-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3290519
30. Bonander CM, Jonsson AP, and Nilson FT. Investigating the effect of banning non-reduced ignition propensity cigarettes on fatal residential fires in Sweden. European Journal of Public Health, 2015; 26(2):334-8. Available from: https://europepmc.org/article/med/26428480
31. Saar I. The effects of the lower ignition propensity cigarettes standards in Estonia: Time-Series Analysis. Injury Prevention, 2018; 24(1):29-34. Available from: https://pubmed.ncbi.nlm.nih.gov/28179374/
32. Butry DT and Thomas DS. Cigarette Fires Involving Upholstered Furniture in Residences: The Role that Smokers, Smoker Behavior, and Fire Standard Compliant Cigarettes Play. Fire Technology, 2017; 53(3):1123-46. Available from: www.ncbi.nlm.nih.gov/pubmed/28751788
33. Commonwealth of Australia. Trade Practices (Consumer Product Safety Standard) (Reduced Fire Risk Cigarettes) 2008. Available from: http://www.comlaw.gov.au/ComLaw/Legislation/LegislativeInstrument1.nsf/0/3FE64581813B093ECA2574C900006E8A/$file/0817073A080829Z.pdf.
34. Weber M. [Must nursing home residents who smoke be supervised? Fire in the nursing home]. Pflege Zeitschrift, 2011; 64(2):112-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21384611
35. Lester PE and Kohen I. Smoking in the nursing home: a case report and literature review. Journal of the American Medical Dirtors Association, 2008; 9(3):201-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18294605
36. Knobloch K, Ipaktchi R, Rennekampff H, and Vogt P. Hand and facial burns related to liquefied petroleum gas (LPG) refuelling and cigarette smoking. An underestimated risk? Burns, 2010; 36(7):e140–2. Available from: www.ncbi.nlm.nih.gov/pubmed/20728999
37. Hawkins S, Hunter J, and Drew P. Domestic automated air fresheners: a significant burns risk to smokers. Burns, 2009; 35(7):1036–7. Available from: www.ncbi.nlm.nih.gov/pubmed/18947928
38. Rughani MG, Furniss D, and Ghosh SJ. Burn injuries from in-car cigarette lighters. Burns, 2010; 36(3):e21-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19427128
39. Lung Foundation Australia. Home oxygen, Australia LF, Editor 2014: Milton, Queensland Available from: https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Home-oxygen-booklet-Nov2014.pdf.
40. Assimacopoulos EM, Liao J, Heard JP, Kluesner KM, Wilson J, et al. The National Incidence and Resource Utilization of Burn Injuries Sustained While Smoking on Home Oxygen Therapy. Journal of Burn Care and Research, 2015. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26284642
41. Al Kassis S, Savetamal A, Assi R, Crombie RE, Ali R, et al. Characteristics of patients with injury secondary to smoking on home oxygen therapy transferred intubated to a burn center. Journal of the American College of Surgeons, 2014; 218(6):1182-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24698489
42. Carlos WG, Baker MS, McPherson KA, Bosslet GT, Sood R, et al. Smoking-Related Home Oxygen Burn Injuries: Continued Cause for Alarm. Respiration, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26812246
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47. Merrill RM. Injury-related deaths according to environmental, demographic and lifestyle factors. Journal of Environmental and Public Health, 2019; 2019(6942787). Available from: https://pubmed.ncbi.nlm.nih.gov/30944571/
48. Knapik JJ and Bedno SA. Epidemiological Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries (Part 1). J Spec Oper Med, 2018; 18(1):108-12. Available from: www.ncbi.nlm.nih.gov/pubmed/29533444
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50. Bedno SA, Jackson R, Feng X, Walton IL, Boivin MR, et al. Meta-analysis of Cigarette Smoking and Musculoskeletal Injuries in Military Training. Medicine and Science in Sports and Exercise, 2017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28614193
51. Brooks RD, Grier T, Dada EO, and Jones BH. The Combined Effect of Cigarette Smoking and Fitness on Injury Risk in Men and Women. Nicotine and Tobacco Research, 2018. Available from: www.ncbi.nlm.nih.gov/pubmed/30053170
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53. Leistikow BN and Shipley MJ. Might stopping smoking reduce injury death risks? A meta-analysis of randomized, controlled trials. Preventive Medicine, 1999; 28(3):255-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10072743