Tobacco Documents Online

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I, THE ISSUE Does other people's smoke cause disoase in nonsmokers? Is the presence of tobacco smoke in the atmosphere cause for a larm ? In the continuing national dialogue on the various issues raised : cigarette s'mokin.g~ .these q'uestions have now come to the forefront~ " " • It has been called the issue of "second hand smoke', "public" or "involuntary" smoking. Unfortunately, as with most controversial scientific:issues, there hasbeen a great deal of mtslnform~tlo~ and dnsubstantla~ed allegations.m~de " about the effect of other people's smoke on nonsmokers. " Because of this misinformation, a maJorl'ty of both smokers and nonsmokers have come to believe erroneously that there is proof that second hand smoke is dangerous to the nonsmoker. This perception is apparently the underlying basis for widespread efforts to prohibit smoking in public • The fact.ls~. To date, dtl~er peopld'ssmo~e has not b~enshb~vnt~ " cause dis'ease In nonsmokers. Because we believe that public policy should be debated and det~rmined on the basis of proven facts, rather than false perceptions., we have prepared this document summarizing ~vhat Is known at thl~ tlme on the question of Second hand smoke.

II, Wi.IAT ARC T//C FACTS ? Numerous scientists, physicians, government officials and heMth expert~ have studied the effect of environmental smoke on nonsmokers. None of these studies have been able to prove that other people's smoke causes disease in nonsmokers. ...... . • A Joint stud~, conducted In 1971 by the Federal Aviation Administration. (FAA) the U.S. Depa~ment of He~lth~ ~u~tfon and Welfare (HE~ ond the National Institute of Occupational Safety a~ Heolth (NIOSH) examfn~ the health aspens of smoking on p~ssenger aircra~. The repo~ of th~s study stated: ~ ... ~it Is concluded that inhalation of the by-pr~u~s from t~acco smoke generated as ~ result of p~ssengers smoking ab~ commercial ~ircra~ d.~s not represent a significant health haza~ ~o non-smok~g passengers. "l ~ In 1977, a~er studying ~ propos~ rule on prohlbitin9 airline pilots from ~moking In the cockpit of commercial planes, the F~ stated: " .... with respect to the a~eged deleterious effe~s of ~rbon mono~de upon the pe~ormance of ~mokfng pilot, the F~ believes that the lnfo~ation presented Is too ~conclusive to warran~ the I~suance of the requested rule at this time. ~ 2 ~ The U.S. Interstate Commerce Commission (ICC), In a 1971 upholding the righ~ ~o smoke on interstate buses, stated: "We agree with the exam~er~s co~clusfons that petitioner has failed adequately to den~onst~ate the .3 d~leterlous effe~s of second-hand smoke upon the health of motorbus passengers.

O Professor Doctor Schievelbeine currently Director of the Institute fcr Clinical Medicine of the German l~eart Center in Munichs concluded in 1973 in an article published in the medical Journal, Internist, that: "No proof of a th,.'eat to the health of nonsmokers through epassive smoking~ can be found in ¢~l.ziies availabte to dat,~." 4 O In 1974 ~ Dr. R. Rylandet:, the Danish medical researchet~, and other leading medical experts organized a workshop in Geneva, attended by scientists from all over the world, to consider the health consequences of atmospheria tobacco smoke° .They concluded: "For the majority of the population the average exposure burden due to environmental tobacco smoke is probab.ly' much lower than that due to industrialair pollutants and in many cases also environmental air pollution or tl-.e lung burden due to dust clouds or other' .5 it.door a~r pollutants. O ~he Bavarian Academ~, of Indh'strial and Social Medlcine sponsored a symposium on smoking lnthe workplace in 1977 in Munich, attended by eminent Get.mare scientlstss lavo, ers and government leaders. In a closing statement, the symposiurn's chairman, Professor Doctor H. Valentin of the University of Er]angen-Nurembur~, said: "In conclusion, with regard to medical and legal facts of passive smoking at the work place, the following must be considered. Under our p~esent day work place conditions, no clear and significant untoward health effects from passive smoking have been shown." 6 N3N • O

O R.S.F. Schilling and a group of co-researchers, thinking that children of smoking parents might contract disease due to their close proximity to smoking family members,, determined exactly the opposite after a study. In ]977, they reported in the American Journal of Epidemioloc~y: "We have found no significant relation ~tWeen parents~ smoking and respi~to~ symptoms or lung ' fun=ion Jn the~f ~ht]dren." They added: '~:~onclu~e tha~ exposure to 1~ " . ' -- level~ of smoke pr~uced by cigarette Smokersdoek not result In chr~i~ ". respiratow symptoms or loss of lung function among chlldmn nor Nmo~adults." 7

0 i'ro[e.~or Doctor '~;chlovuilJ~:Jn, currezztly Dlructor of the Institute for Clinico] Medicine of the German llcart Cuntur In Mmllch, concluded In 1973 in an article published in the mudica] Journal,.Intornls._~t ,'that: proof of a threat to the health of nonsmokers through 'passive smoking' can be found in studies available to date," 4 O In 1974, Dr, R. Rylunder, the Danish medical researcher, and other lea~ing medical expects organized a workshop in Geneva,.attended ~by ~c!enti.sts from all over the w.or~d, to co.nsidor ,the. health consequences of atmospheric tobacco smoke, They concluded: • "For the maJor.ity of the population the average exposure burden due to environmental tobacco smoke is probably much lower than that due to industrial air pollutants and in many cases also ereironme~zal air pollutiot~ or t},e lung burden due to dust clouds or other indoor" ~ir pollutants." 5 0 The Bavarian Academy' of Industrial and Social Medicine sponsored a symposium on smoking ln the workplace In 1977 in Munich, attended by' eminent German scientist-~, lawyers and government leaders. In a closing statement, the symposlum~s -chairman, Professor Doctor H o Valentln of the University of r.rlangen-Nuremburg, said: "In conclusion, with regard to medical and legal facts of passive smoking at the work place, the following must be considered. Under our present day work place conditions, no clear and significant untoward health effects from passive smoking have been shown." 6 --5-- U~

III. SUPPORTING OPINIONS j' Others who have studied the effects of smoking on nonsmokers have confirmed these [tndings. <) Dr. D .M. Avlado, Professor of Pharmacology for the University - of Pennsylvania said, in a statement before the Council of the District of Co]umbia Committee on Transportation and Environmental Affairsi~1976: "On the basis of existing scientific evidence, tobacco smoke constitutes no health hazard to nonsmokers in.public places." 8 ... O In a statement In 1977 before the New Iersey Public Health Council, Dr. Walter M. Booker, Emeritus Professor of Pharmacology of Howard University, . said: "As a scientist, I am interested In actual data which demonstrate whether a nonsmoker absorbs tobacco sm'oke and, if so, whether the amount Is sufficient to cause adverse physJologJca] eHects. Theliterature sJmply does not support the theory that a non~moker absorbs amounts which can cause harm."9 " I~ Pathology l~rofess~r Dr. Edwin R. l~isher of the University of Pittsburgh, appearing before the same New 1ersey ~roup Jn 1977 said; "My careful review of the literature, confirming the conclusions based upon my own ex'per'.mental data and the related work discussed above, reveals a lack of . scientific information which would allow me to. conclude that atmosPheric.tobacco" smoke or its constituents represent a health hazard tn nonsmokers." 10 -6-

(~ Writing In the San Francisco Examiner In I977, medical researcher Dr. C.H. lithe said'. "The medical literature to date does not Indicate any significant health risk to the nonsmoker from environmental tobacco smoke normally encountered In day-to-day situations. ,,!! (~ Appearing before the New 1ersey Public Health Council in 1977, Dr. Charles L.. WaRe, Retired Rear Admiral of tl~e U.S. NavF Medical Service, • Medlca! Director of the Tobacco Institute, and Fellow of the American College of Physicians, made the fol~ow~.ng statem.ent: "Zn r~,F opinion, there Is no convincing evidence to support the hazards claimed by some to the effect tl~t cigarette smoke threatens the health of the average wel! nonsmoker. On the basis of existing scientific evidence, ! can only conclude that tobacco smoke constitutes no health hazard to nonsmokers In public places."12 O And0 in a 1976 German medical Journal (Zbl. Bakt. Hyg., Io .Abt. Orig. 162:51 2-69) Dr. W. Klosterkotter and Dr. E. Gono, of the Hospital of the Unlversity of Essen, W. Germany, and two fellow Wes~ German doctors said, fo]lowlng their research: "So far passive smoking has not proven to ba health- hazardous in healthy adults. Thus an Important condition for a legal smoking ban, e.go at places of work, remains unfilled. "13 . OPPONENTS OF SMOKING AGREE Even the most avowed critics of smoking acknowledge that smokln~ has not been establlsh.ed as a cause of disease tn nonsmokerso Some of them include." O The then U.S. Surgeon General, Jesse Stelnfeld, who stated after issuing the 1972 Public Health Service Report on Smoking: "(I cannot) say with

certainty that exposure to tobacco smo|:t; can cause serious illness in ,, 14 nonsmokers. O Dr. ~onathon Rhoades, Chairman of the National Cancer Advisory Boards said In 1975 that to his knowledg~ "It is not, in feats actually harmful." 15 ~ Dr. E. Cuy]er Hammond of the American Cancer Society said In 1975 that there "was no shred of evidence" that a nonsmoker can get cancer from "second hand" smoke~ He added it=at to suggest second hand smoking cot~ld cause cancer Is dishonest, and that he would be prepared to testify, to that in court. 16 O The "Expert Group" appointed by' the British organization, Action on Smoking and. Health (ASII), headed b~, Dr. Charles Fletcher of the British Royal College of Physlcian!~, concluded In 1973 that: "There Is no evidence, that other ~eop]e's smoke ts dangerous to healthy nonsmokers ..... = ]7 (~ American Cancer Society official Lawrence Garflnkel said In 1976: " ..... (T)here is no evidence, however, that nonsmokers who are constantly exposed to cigarette smoke have a higher Incidence of bronchial carcinoma o" 18 1t~ Great Britain% Foreign Minister Dr. David Owen, while serving as Minister of Health In 1975 said: "No clear evidence has yet been published to show that tobacco smoke Is harmful to rtormally healthy nonsmokers or that a. heavily tobacco-smoke laden atmosphere has other than a transient e£fect.." ]9 O In a 1977 television appearance In V~rashlngton, D.C. on W3~OP-3~/ (CB9) Dr. Gto Gorl state~: "I would say that the evidence that we h~ve today,

scientific evidence, sornothlng that we can prove, or normal ~moklng conditions that you may have a couple of people smoking in a regular size room, the health effects connected with thai ore probably going to be minimal.''20 (~ Three spokesmen for the Naylor Dana Institute for Disease " Prevention of the~mer~can Health Foundation, including Dr. ErnestLo Wynder, ~...; concluded that: "Specifically, we know of no data :suggestihg : ~~: ~- .... :~~; ~ " that passive lnhalattOn.og cigarette smoke increaseg:ih~"rlsk oi:de~loping lung'cancer:" In addition, they" reported: "On the basis of available ~pideml¢~l¢~lc~l evidence, it appears that passive inhalation of tobacco smokeby nonsmokers"or ~oket:s .... does not increase their risk for chronic illnesses-such as cancerof the .... respiratory ira bt, emphysema, or cardiovascular disease

IV. REFUTING FALSE CLAIMS Although there is no convincing proof to date to show that other people=s cigarette smoke causes disease in nonsmokers, a number of false allegations bearing on this subject have been widely publisbed. Some of the more common claims are listed below accompanied bY the facts': Claim: Smoking causes chronic deqenerative diseases in nondmokers. Fact : There is no scientific basis for such claims. An American Cancer Society epidemiologic'al study in 1976 found no proof that nonsmokers 22 constantly exposed to tobacco smoke have Increased risk of lung cancer. Claim: Atmospheric tobacco smoke causes or contdb~e~ to the development of ~therosc;:. :osls (a disease characterized by~ lnelastlclt~_a~., thickening of arterial vessel walls) ,i..n nonsmokers~ as a result of carbon monoxide, Fact : Studies conducted onanimals .chronically exposed to carbon monoxide compared with a;~ima]s not so exposed showed that these animals had 23 arterial changes which duplicated early atherosc]erosls. However, these tests ignored observations in human t~ridge and tunnel workers which showed that those persons 0 also chronically exposed to carbon 24 mono~de did .n~. have any increased incidence of atherosclerosis. The original experimenter, P. Astrup, has admitte.d that he is unable to reproduce his previous experiment and thst his "present ~tudy suggests -]0-

that applying the oenera]Jy accepted crJtnrla for |nI|mal (membrane or ]inlno of an organ) damaQe, no direct toxic effect of CO can be demonstrated," 25 Claim: Par~[a] ~'~o~ln~ cause~"~irato~ Illness Foct : A Qroup o~ researchers studJed respJrato~ s~mptoms~ diseases and lung fun~on In 376 ~amllles with 816 children In three towns "~ound no s~Qnlftcant reJatdon between parental smoking and resplrato~ s~mptoms or ]unu function. In their children," T~e~ concl~ed:"~hat exposure to low Jeve}s o~ smoke pr~uced b~ clga~tte smokers does not result in c~onlc re~pirato~ symptoms or loss of lu~ function among ... children or among adults Another recent clinical study confirms the same f~d~gs. The study determined that:'Smoking and nonsmoklng parents have abc~ the-same propo~ion of children with resplratow symptoms. ~he nu~er of cigarettes smoked by the parents has no influence ~ ~sp~tory symptoms ~ their chil~n..." Claim: Cigarette Smoke causes resptrato~ a~le~ies. Fa~ : Claims ab~t tobacco alle~y stem p~marllY from the man~ st~les In • • which e~ra~ from tobacco leaf has been tested a~ fo~d to cause alle~lc 28 response In people who are otherwise a~e~ic. However, these tobacco leaf e~ract st~les do not resolve the.issue, and despite.the claims of one, others-are unable to identify any alle~ens in tobacco smoke. 29 ' work is still being done In this area.

Claim; Asthmatics are believed to be particularly vulnerable to tobacco smoke. Tact ; A recent studl? failed to find any significant changes in the lung function of asthmatics who had been exposed to cigarette smoke in a small test chamber. 30

.V, CARSON MONOXIDE AND OTHER ENVIRONMENTAL FACTORS Some nonsmokers have expressed concern over the presence of tobacco smoke in the atmosphere. " Studies measuring tobacco smoke constituents in the atmosphere under realistic conditions have not found levels sufficiently high to Justify' such concern.. The level set by the UoS o Occupational Safety and H.ealth Administration (OSHA) as the limit for Industrial exposure over an eight hour • " period Is 50 parts .per million (ppm)o The combined results of studies on the amount of carbon monoxide in the atmosp.here fi'om Smoking indicate that, under realistic conditions, carbon monoxide in the .~tmosph.ere from .smoking will 31 l-tire1), exceed 10 ppm. One exception was reported in a study of a sports arena whioh permitted smoking but was not air conditioned, causing the carbon monoxide level to reach 25 ppm.32Other exceptions were studies performed in taverns 33 and nightclubs where carbon monoxide levels as high as 42 ppm were recorded. However, ~hese studies were conducted with an instrument that is known to exaggerate the. level of carbon monoxide in the presence of alcohol vapors. Combined results of studies of COHb*levels In smokers and in non- smokers exposed to tobacco smoke indicate that,under realistic conditions, . smokers will rarely experience COHb levels greater that. ten percent and that nonsmokers usually will not exceed two to three percent. And~ even these relatively low levels of COHb will drop within a few hours after the cessation .34 of exposure to smoke *the combination formed by carbon monoxide and red blo~ pigment

Some nol~smokors also complain about the alleged buildup of carbon monoxide in offices ~:nd other placos where smoking Is allowed. Yet, one recent study showed that the COllb levels o! office workers were higher when they came to work than when they left at the end of the day, ev~,n though they were exposed to cigarette smoke throughout the day.35Clearly, the real concern should be for th~ outdoor levels of carbon monoxide from car exhaust and other sources to which nonsmokers are exposed on their way to work. No one has ever established that the health of nonsmokers is adversely affected by even the smag amount of ~rbon monoxide that might be in the atmosphere due to cigarette smoke. CO is a natural b~y constituent which Is present in the blo~ without any exposure to CO In the atmosphere, and the b~y can a~ d~s eliminate CO by various means. Persons with CO~ levels of 15 percent or less rarely even suffer any of the first symptoms of CO 36 difficulties such as.headaches a~ nausea. A claim frequently made about 3):pcsure to low levels of CO Is tha~ it affects ce~ain perfo~ances, such as the ability to distinguish ~tween sho~ ~te~als of time or to solve mathematical problems~ B~ them Is still scientific disagreement about whether such performances are alleged by COHb measurements In the neighborho~ of ten percent or less. Some studies indicate .that these levels of CO will affect such performance,3~hlle other 38 studies do not ~o indicate. This area requires additional research. It also has been alleged that persons with severely compromised cardiovascular systems are ~dversely affected by environmental tobacco smoke,

especially, carbon monoxide. This belief stems largely from Aronow's studies of angina patients In which he used "pure" carbon monoxide, as well as tobacco smoke, to elevate their COHb levels. He found that a certain COHb level obtained by exposure to "pure" carbon monoxide caused certain changes in cardiac funotion~ but that the same COHb level obtained from tobacco smoking did not result in 39 such changes. While the reasons for these differences in cardiovascular function are as yet unknown, the author suggested that it might be due to "nicotine which antagonizes the negative inotroplc effect of carbon monoxide. "4~v~rhatever the reason for these findings, this study is not conclusive. This Is another area where further research is'needed. Studies of other tobacco smoke constituents Indicate that smoke's 41 contribution to atmospheric levels of ~hese compounds ts minimal. Such studies are usually conducted as the result of a claim about the danger of exposure to some compound attributable to tobacco smoke. One such study of "volatile" organic-compounds, recently concluded that the amount of such compounds added to the atmosphere as a result of cigarette smoking is 42 "insignificant." As to nicotine, research shows that low a.tmospherlc levels result from cigarette smoke.43No one has suggested that the minuscule amount of nicotine that might be absorbed by a nonsmoker has any:hing todo with the production of human disease. In fact, a recent study monitoring heart rates

of nonsmokers exposed to cigarette smoke under laboratory, conditions ~ r concluded that the amount of nicotine Inhaled by nonsmokers under their i: rigorous test conditions was too small to alter heart rate° 44

VI,, ,THE ANNOYANCE FACTOR All of the foregoing establishes, in our Judgement, that there Is no physiological basis for claiming that other people's smoke causes disease '~" in:the nonsmoker, Despite that fact, it Is ,~lear that cigarette smoke does annoy some people. Tobacco smoke may "drift= into the eyes or nose of the nonsmoker who may be annoyed by the smell~ In places that are poorly , ventilated, high concentrations with other environmental impingements may cause eye or nasal irritation. At least one scientist, Dr. Gary H,uber, .suggests that the odor of smoke components "may tri.~ger emotJonal responses not yet we~ understood." Support for this theory was found in e recent study in which college students were first characterized as to their ettitudes concerning tobacco smoke and then were exposed to such smoke.46The heart rates of those who "disliked" smoke '! were much higher than those who were. =Indifferent" ~o smoke. There was no way to determine from the data whether initially the "dislike" group had a higher heart rate or whether the anticipation of sitting and Inhaling the "disliked" cigarette smoke caused an increased heart rate. .. Yet some studies suggest that the vast majority of ~okers and nonsmohar-'-" ;=re not usually annoyed.by public smoking. For example, a recent U.S. survey conducted by Response Analysis in Princeton, people were asked about the kinds of things that annoyed or Irritated them in

their everyday lives, only about two percent of the ~nnoyances mentioned were related to smoklng.47And, 91 percent of those In the survey didn't even mention smoking. 48 The American Express Company found little interest In nonsmoklng travel tours,4~nd e Seattle, Washington, reStaurant reported that there were only seven requests for seating in the nonsmoklng section during a .three-month 50 period when they' served 30,000 customers. All of this suggests that the Issue of other people's smoking really falls into the category of annoyances -- akin to other everyday annoyances, such as barking dogs, loud music, personol eating habits, etc. Smoking Is like any other habit or practice with the potential of annoying others. In our society, such annoyances are alleviated through the traditional rules of common courtesy. The "second hand" smoking problem addressed In this paper would surely begin to disappear if smokers were more sensitive to the feelings of nonsmokers and practiced simple rules of courtesy in dealing with the problem. One fact Is clear: Although atmospheric tobacco smoke may be annoying to some people, It has not been proven to cause disease in nonsmokers. # # # #

REFERENCES 1. U.S. Dept. of Transportation, Federal Aviation Administration, U.S. Dept. of Health, Education, and Welfare• National Institute for Occupational Safety and Health• Health aspects of smoking in transport a-'rcraft Rockville, Md AD 736097, December 1971. 85 pp. 2. Department of Transportation, Federal Aviation Administration, Reg. Docket No. 15614, In the Matter of the Petition of the Airline Pilot's Committee of 1976, The Public Health Citizen's Health Research Grcup, and the Aviation Consumer Action Project, Decided August 22, 1977. 3. U'S. Interstate Commerce Commission. Smoking by passengers and operating personnel on interstate buses. Washington, D.C. No. MC- C-6748, Motor Carrier Cases, 114: 256-278; November 17, 1971. 4. Schlevelbeln, H. "On the question Of the effect of tobacco smoke on the morbidity of non-smokers." Internist 14 (5): 236-243; 1973, 5. Corn, M., et al. Workshop summary and recommendations. Report from a workshop on Environmental Tobacco Smoke Effects on the Non-Smoker~ Bermuda, March 27-29, 1.o74. Scand. ]; Resp. Dis,. Suppl. 91: 88-90~ 1974. . 6. Valentin, H. In: Passive Smoklnq at the Workplace. Reports and discussions from a meeting of.the Bavarian Academy of Industrial and Social Medicine, March 31-April ], 1977, p. 24. 7. Schilling, R.S.F., Letal, A.D., Hut, S.L., Beck, G.J., Schoenberg, J.B., Bouhuys, A. "Lung function, respiratory disease and smoking in families." .Am. ~. Epidemiol. 106 (4): 274-283~ 1977. 8. Avlado, D. M., Statement before the Public Hearing before the Council of the District of Columbia Committee on Transportation and Environmental Affairs, pp. 1-6, April 27, ]976. 9. Booker, Walter M., Statement Before the New Jersey Public Health Council, Trenton, N.J., October 20, 1977• I0. Dr. Edwin R. Fisher, Professor of Patholo2y, University of Pittsburgh, in a Statement Bdore the New Jersey PubIlc Health Council, Trenton, N.J., October 20, 1977.

REFERENCES - Cont'd 11. Hlae, C. H., "Second-Hand Smoke - Is It llarmful?," San Francisco _E.xamlner, p. 37, August II, 1977. " ]2. WaRe, Charles, L., Statement before the New Jersey Public Health Council, Trenton, N.J., October 20, 1977. 13. Klosterkotter, W. And E. Gono, "The Problem of Passive Smoking" (Zum Problem des "Passivrauchens"), Zbl. Bakt, Hyg., I, Abt. Orlq. 162:51-69 (Translation from German). j . 14. Steinfeld, ]. L. II. The public's responsibility: a bill of rights for the non-smoker. Rhode Island Med. I. 55 (4): 124-126, 138; 1972. 15. Rhoades, Jonathan Jr., Comment during "A discussion of smoking and health", Newsprobe, WTAF-TV, Philadelphia, Pennsylvania, p. 9, July 16, 19 75. ]6. Hammond, E.G. "What are the high rlsk group~ for public education? How dles epldemiology Identify them?" In: Summar~ Proceedings of tho International Conference on Public Education About Cancer. UICO Technical Report Se(J.es., Vol. 18, Geneva, 1975, p. 13. 17. Action on Smoking and Health. "Pipe and cigar smoking: the report of . an expert group appointed by 'Action on Smoking and Health'." The.. Practitioner 210 (1259): 645-652; 1973. 18. "Non-Smokers Needn't Fear Cigaret Smoke, Study Says," Tucson (Ariz.) Star., April, i976. 19. Owen, D. "Smoking in Public", British Meal. J. 2: 399-400; May 17, 1975. 20. Gori, Gio, "Nine in the Morning," WTOP-TV, CBS, Washington, ~anuary 4, 1977. 21. Wynder, E.L. Statement made on Barbara Walter's television.program "Not for Women Only". WRC-TV, NBC Network,. Washington, D.C. April 18, 1974, 9:0n .~.M. Radio TV Reports, Inc. Washington, D.C. p. II.

REFERENCES - Cont'd 22. Garfinke], L. "Questions and answers on cancer: branchia! ca in non-smokers." CA - A Cancer Iournal for C]lniclan.~ 26 (3): 181-182; 1976. 23. a) Astrup, P., KJe]dsen, K., Wanstrup, I. "Enhancing influence of carbon monoxide on the development of atheromatosis in cholesterol- fed rabbits." [o Atheroseler. Res,. 7= 343-354; 1967. b) Wanstrup, ~., KJeldsen, K., Astrup, P. "Acceleration of spontaneous intimal-subintimal changes in rabbit aorta by a prolonged moderate carbon monoxide exposure. Aeta. Path. Microbiol. Scand. 75: 353- 362; ]969. .. • c) KJeldsen, K., Astrup, P., Wanstrup, ]. "Ultrastructural intimal changes in the rabbit aorta after a moderate carbon monoxide expc, sure," Atherosc]erosls ]6 (l); 67-82; ]972. d) KJeldsen, K., Thomsen, H.K., Astrup0 P. "Effects of carbon monoxide on m~,ocardiumo Ultrastructural changes in rabbits af-~er moderate, • '- March 1974. chronic exposure. = Circulation Research 34 (3:, 339-348, e) Thomsen, H.K., KJeldsen, K. "Threshold limit for carbon monoxide- induced myocardial damage. An e]ectron microscopic study in rabbits." /~rchives of Environ. Health 29 (2): 73-78, August ]974. 0 Thomsen, H.K., KJeldsen, K. "Aortic inttmal injury in rabbits: an evaluation of a threshold limit." Arch. Environ. Health 30 (12): 604- 607; 1975. 24. Ayres, SoM., Evans, R., Licht, D., et al. "Health effects of exposure to high concentrations of automotive emlssiOnSo Studies in bridge and tunnel workers in New York City." Arch. Environ. Health 27 (3): 168- 178; 1973. 25. a) Hugod, C., Hawkins, L., KJeldsen, K., Thomsen, H.K., Astrup, " P. "Influence of carbon monoxide on intimal morphology." .Paper presented at the International Conference on Atherosclerosls, Milan, Novsmber 9, 1977. b) Stender, S., Astrup, P., KJe]dsen, K. "The effect of carbon monoxide on cholesterol in the aortic wall of rabbits." Atherosclerosis 28: 357-367; 1977.

26. Schilling, R.S.F., Letal, A.D., tlui, S.L.. Beck, G.J. ].B., Bouhuys, A. "Lung function, respiratory disease and smoking in families." Am. 1. Epidemio]. 106 (4): 274-283; 1977. 27. KerrebiJn, K.F., Hoogeveen-Schroot, tI.C.A., Van der Wa|, "Chronic nonspecifJc respiratory disease in children, a five year follow-up study." Acta Paed. Scand. Suppl. 26l: 1-72; 1977. '! 28. a) Harkavy, 1, "Tobacco allergy in cardiovascular disease; a review." Ann. Allergy_ 26: 447-459; 1968. . b) Fontana, V.T., Redtsch, W., Nemir, R.L., Smith, M.K., De:finis, " K., Sulzberger, M.B. "Studies in tobacco hypersensitivity IlI. Reactions to skin tests and peripheral vascular responses.= 1- Allergy 30: 241-249; 1959. .. c) Peshkfn, M.l~4., Landay, L.H."Cutaneous reactions to tobacco antigen in allergic and nonallergic children with the direct and indirect (local passive transfer) methods of testing. = ~. Aileron, 10 (3): .241-245; 1939 d) Speer, F. "Tobacco and the non-smoker. A study of subjective symptoms.= Arch. Environ. Health 16(3): 443-446; 1968. 29. McDougall, J.C., Gliech, G.]'. "Tobacco allergy -- fact or fancy?" _T. Allerqy Clln. Ir~munol. 57 (3): 237; 1976. 30. Pimm, P.E., Shepherd, R.I., Sllverman, F. "Physiological effects of acute passtve exposure to cigarette smoke in asthmatics.= Fed. Proc. 36 (3): 606; 1977. 31. a) Andersson, G., Dalhamn, T. "Health rl~ks due to passive smoking." Lakartidn. 70: 2833-2836; 1973. b) Bridge, D.P., Corn, lV[. "Contribution to the assessment of exposure of non-smokers to air pollution from cigarette and cigar smoke in occupied spaces." Environmental Res. 5 (2): 192-209; 1972. c) Cole, P.V. "Comparative effects of atmospheric pollution and ciga,eCte smoking on carboxyhemoglobin levels in man." Nature 255 (5511): 699-701; 1975. IV

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