Review Paper Does adherence to the Mediterranean diet have a protective effect against active and passive smoking? C.I. Vardavas a,b, *, A.D. Flouris c , A. Tsatsakis d , A.G. Kafatos a , W.H.M. Saris b a Department of Social Medicine, Faculty of Medicine, University of Crete, Greece b Nutrition and Toxicology Research Institute Maastricht, Department of Human Biology, University of Maastricht, The Netherlands c Institute of Human Performance and Rehabilitation, Centre for Research and Technology, Thessaly, Greece d Centre of Toxicology Science and Research, Faculty of Medicine, University of Crete, Greece article info Article history: Received 29 September 2009 Received in revised form 21 June 2010 Accepted 16 November 2010 Available online 28 January 2011 Keywords: Smoking Mediterranean diet Passive smoking Antioxidants summary Objective: To investigate the existing evidence about whether adherence to the Mediterra- nean diet may have a role as an effect modifier of active and passive smoking on human health. Study design: Review. Methods: An overview of emerging evidence and published studies that cover the interac- tion between the Mediterranean diet and smoking. Results: Both epidemiological and laboratory studies have shown that the Mediterranean diet has a protective effect against biochemical and molecular processes that lead to cancer, cardiovascular disease and respiratory illness. Based on the high daily intake of vitamins and antioxidants, the Mediterranean diet is comprised of a number of compounds that could alter certain outcomes related to smoking. Studies have indicated that certain diseases attributable to smoking, such as lung cancer, asthma and cardiovascular disease, are inversely associated with certain antioxidants and lipids. Conclusions: The literature indicates that the existence of a partial interaction between adherence to the Mediterranean diet and the health effects of smoking is possible. Further research is needed to lead to a conclusive statement on this hypothesis. ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Introduction Detrimental effects of active and passive smoking Smoking is one of the largest causes of preventable death, and is expected to kill 1 billion people prematurely this century. Second-hand smoke (SHS) is another serious threat to public health, subsequent to tobacco use, and is a potent mixture of carcinogens, volatile toxins and chemicals. 1e3 It has been estimated that, worldwide, at least 1 billion adults are smokers and at least 700 million children breathe air polluted by tobacco smoke at home. 4 SHS exposure is related to the ever-increasing frequency of diseases among children and adults, such as respiratory illness, asthma, otitis media, sudden infant death syndrome and vascular dysfunction, and predisposition towards cardiovascular disease and cancer. 5e8 * Corresponding author. Faculty of Medicine, University of Crete, PO Box 2208, Heraklion 71003, Crete, Greece. Tel.: þ30 2810 394599; fax:þ30 2810 394606. E-mail address: vardavas@edu.med.uoc.gr (C.I. Vardavas). available at www.sciencedirect.com Public Health journal homepage: www.elsevier.com/puhe public health 125 (2011) 121 e128 0033-3506/$ e see front matter ª 2010 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2010.11.012