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1' EPA/400/6-90/004 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE ENVIRONMENTAL TOBACCO SMOKE: A GUIDE TO WORKPLACE SMOKING POLICIES June 25,1990 Public Review Draft NOTICE THIS DOCUMENT IS A PRE .IMINARY D FT AND SLBJECT TO A 1`* F IT HAS NOT BEEN FORMALLY RELEASED BY THE U.S. ENVIRONMENTAL PROTECTION AGENCY AND SHOULD NOT BE CONSTRUED TO REPRESENT AGENCY POLICY. IT IS BEING CIRCULATED FOR COMMENT ON ITS TECHNICAL AND POLICY CONTENT. Indoor Air Division Office of Atmospheric and Indoor Air Programs Office of Air and Radiation U.S. Environmental Protection Agency

DISCLAIMER THIS DOCUMENT IS A PRELIMINARY DRAFT AND SUBJECT TO CHANGE. IT HAS NOT BEEN RELEASED BY THE U.S. ENVIRONMENTAL PROTECTION AGENCY AND SHOULD NOT BE CONSTRUED TO REPRESENT AGENCY POLICY. MENTION OF TRADE OR COMPANY NAMES DOES NOT CONSTITUTE APPROVAL OR ENDORSEMENT.

NOTE TO REVIEWERS This draft document is part of EPA's overall effort to characterize indoor air pollution problems and develop stra.tegies for reducing the public's exposure to indoor air contaminants. It is also part of an EPA initiative to address one of the most prevalent and harmful indoor air pollutants: environmental tobacco smoke (ETS). The National Cancer Institute has collaborated in the development of this draft document. EPA is transmitting this document to its Science Advisory Board (SAB) for comment along with a formal risk assessment of ETS entitled "Health Effects of Passive Smoking: Assessment of Lung Cancer in Adults and Respiratory Disorders in Children" (EPA/600/6-90/006A). The risk assessment seeks to classify ETS according to EPA's carcinogen risk assessment guidelines, to estimate the excess lung cancer deaths attributable to ETS exposure, and to assess the association between passive smoking and respiratory effects. The risk assessment and this document will be the subject of an SAB review meeting. Persons interested in providing comments may obtain a copy of the draft risk assessment by contacting: ORD Publications Office, CERI-FRN U.S. Environmental Protection Agency 26 West Martin Luther King Drive Cincinnati, Ohio 45268 (513)569-7562; FTS 684-7562 A formal Notice of Availability appears in the Federal Register. This document is intended to provide government and private sector decision makers with information on the technical basis for controlling involuntary nonsmoker exposure to environmental tobacco smoke and to describe a variety of technical and policy options for instituting effective smoking restrictions. The draft policy guide includes some information from the as-yet-unfinalized risk assessment. BOTH DOCUMENTS ARE REVIEW DRAFTS - PLEASE DO NOT CITE OR QUOTE. BECAUSE INFORMATION CONTAINED IN BOTH THE POLICY GUIDE AND THE RISK ASSESSMENT IS UNDERGOING REVIEW AND IS SUBJECT TO CHANGE, THESE DOCUMENTS DO NOT REPRESENT AGENCY POLICY. Please review this draft for technical accuracy, completeness, and effectiveness in communicating with a predominantly non-technical audience. Comments MUST BE IN WRITING, POSTMARKED NO LATER THAN AUGUST 31,1990, and should be mailed to: ETS COMMENTS Indoor Air Division (ANR-445) EPA, 401 M Street, SW Washington, DC 20460 OD FAX #: (202) 382-7991 ~ C!1 W V1 ~

y 1% Table of Contents Acknowledgements Introduction .................................... .......:............................................................ Key Points .................................................................................................... ........ I 3 Recornmendations ........................ ................. ................. _................................ 5 Part I - ENVIRONMENTAL TOBACCO SMOKE: THE PROBLEM..... 6 Chapter 1 - What is ETS? .................................................................................. 7 Chapter 2- Measuring ETS in the Air and Body ........................................ 11 Chapter 3- Health Effects of ETS ....................................... ............................. 15 Chapter 4- How Big is the Risk from ETS? ................................................. 19 Part II- ENVIRONMENTAL TOBACCO SMOKE: THE SOLUTIONS. 21 Chapter 5- Reducing Exposure to ETS ......................................................... 22 Chapter 6- Regulating Smoking and ETS ................................................... 26 Chapter 7- Developing Effective Smoking Policies .................................. 33 Chapter 8- Cost Savings Related to ETS Reduction .................................. 37 Chapter 9- Public Attitudes Towards ETS ................ »................................. 41 Part III - CASE STtJDIES ............... ........ _........ ................................................. 42 Chapter 10 - Smoking Policies in the Private Workplace ...................... 43 Chapter 11 - Smoking Policies in Government Facilities ...................... 50 Chapter 12 - Smoking Policies in Health Care Facilities ......................... 55 Chapter 13 - Smoking Policies in Schools...... » .......................................... 60 Resources ........... ......... ...... ........... ..»......................... ...»........ ............................. Footnotes ................. .._............. ......... ....»..... ».... ............. ................ ................... 63 65 PUBLIC REVIEW DRAFf - DO NOT CITE OR QUOTE

Acknowledgments This publication was prepared by the Indoor Air Division of the Office of Air and Radiation, United States Environmental Protection Agency, Washington, D.C. It was developed in collaboration with the Smoking, Tobacco, and Cancer Program of the National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Washington, D.C. The publication was written by Robert Rosner and Robin Simons of the Smoking Policy Institute, Seattle, Washington. Information for Chapter 9, Developing Effective Smoking Policies, was drawn from "90 Days To A Smoke Free Workplace," Copyright ®1987, Smoking Policy Institute. The authors acknowledge with gratitude all of the individuals and organizations who provided support and assistance during the development of the report. Special thanks to Robert Axelrad and Jim Repace of the Environmental Protection Agency; Donald Shopland of the National Cancer Institute; C. Everett Koop, Former Surgeon General; Thomas Novotny of the Office of Smoking and Health; William Cain and Brian Leaderer of Yale University; Jonathan Samet of the University of New Mexico; John Spengler of Harvard University; and Jennifer Stock, Bill Weis and Tim Lowenberg of the Smoking Policy Institute. For assistance in developing the case studies the authors wish to thank Len Beil of U.S. West Communications and Sue Pisha of the Communications Workers of America; Caren Olsen, Bill Heim and Lynn Warne of Honeywell; Lee Fairbanks of the US. Indian Health Service; Howard Strickler of the City of Bellevue; Martha Riddell of the Lexington Clinic; Ray Zoellick of Swedish Hospital; and Dennis Underwood of the Andover Public Schools.

Introduction There are many potential sources of indoor air pollution, including chemicals emanating from building materials, furnishings, and consumer products; gases from combustion appliances like space heaters and furnaces; and biological contaminants from a variety of sources. However, field studies, controlled experiments and mathematical models have shown that Environmental Tobacco Smoke (ETS) is one of the most widespread and harmful indoor air pollutants and is a major contributor to particulate indoor air pollution. The smoke emitted by cigarettes, cigars and pipes contains over 4,000 chemicals, many of which are known carcinogens and toxins. These are inhaled by smokers during the process of smoking, and by nonsmokers who breathe the ETS emitted into the air. The breathing of ETS by nonsmokers is called "passive," "involuntary," "sidestream" or "secondhand" smoking. The effects of smoking on smokers have been examined in over 50,000 studies conducted over the last 25 years. These have shown that cigarette smoking causes lung cancer, chronic obstructive lung disease, and coronary heart disease. According to the Surgeon General, cigarette smoking is the chief avoidable cause of death in the United States, with the number of premature deaths due to smoking estimated at 390,0001 annually. The Office on Smoking and Health reports that smoking causes more premature deaths every year than cocaine, heroin, alcohol, fire, automobile accidents, homicide and suicide combined.2 The Environmental Protection Agency (EPA) presumes that there is no such thing as a risk-free exposure to a carcinogen. Unless there is evidence to the contrary, EPA believes that any exposure to a cancer causing agent regardless of level-increases the risk of cancer. The fact that active smoking causes lung cancer, therefore, suggests that nonsmokers exposed to ETS are also at risk for lung cancer, although at a much lower level than smokers. Recently, scientific studies have examined the link between ETS and lung cancer. In 1986, two major independent reviews examined the impact of ETS on public health. Commissioned by the US. Public Health Service (PHS) under the Surgeon General, and by the National Research Council (NRC) at the request of EPA and PHS, both groups arrived at the same conclusion: exposure to ETS significantly increases the risk of lung cancer. Moreover, there was agreement that ETS exposure substantially increases respiratory illness in children and aggravates the conditions of people with heart disease. In 1990, EPA completed a risk assessment of the health effects of ETS. The report examined the 24 epidemiological studies which have studied the level of risk of lung cancer from exposure to ETS. The risk assessment reached the following conclusions: According to the EPA classification of carcinogens, ETS is a Group A Carcinogen. Carcinogens are agents known to cause cancer in humans. Group A Go ~ ~ C!1 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 1 W W m CD

The number of ETS-attributed lung cancer deaths in U.S. never-smoking adults is approximately 2,500 annually. The excess number of ETS-related deaths in former smokers is estimated at about 1,300 annually. The evidence linking ETS exposure to increased lung cancer incidence can not be attributed to chance 3 There are also serious non-carcinogenic effects from ETS. In particular, there is a strong association between ETS and respiratory effects on children and there is mounting evidence of heart disease mortality in nonsmokers from passive smoking. The evidence of ETS lung cancer and respiratory disease risks is particularly strong since ETS has been demonstrated to cause health effects at low levels of exposure. The public health implications of these findings are significant because of the large numbers of people exposed. Tobacco smoke is virtually ubiquitous in our society. Studies show that between 26%4 and 29%5 of the US. adult population smokes. This is a decline of almost one-third since 1964.6 However, the people who continue to smoke smoke more than they did before. According to the National Research Council, reported cigarette consumption among heavy smokers has increased from 27.3 to 30 cigarettes per day, and the number of heavy smokers has steadily increased over the past 30 years. As a result, the number of cigarettes smoked each year in the United States has -increased, and "the nonsmoker who has close contact with a smoker may be exposed to greater amounts of smoke in 1985 than in 1955.'7 The magnitude of the problem led the Surgeon General to state in 1986 that "the scientific case against involuntary smoking as a public health risk is more than sufficient to justify appropriate remedial action, and the goal of any remedial action must be to protect the nonsmoker from environmental tobacco smoke."8 Heeding his words, many nonsmokers have become concerned about their exposure to ETS, and many businesses and governments are now taking steps to protect them from it. This publication is designed to help the non-expert understand the technical basis for smoking restrictions and to provide guidelines for implementing them. It explains the physical and chemical nature of ETS, how ETS exposure occurs, how it is measured, and the health effects of exposure. It examines passive smoking in the workplace and other sites, and examines legislative, legal, financial, educational and labor concerns. It includes different strategies for reducing exposure to smoking at the workplace along with case studies of policies that have been successfully implemented. Finally it contains a list of resources for those interested in additional information. 2 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE

Key Points What Is ETS? Environmental tobacco smoke (ETS) is primarily a combination of sidestream smoke from the burning end of the cigarette, pipe, or cigar, and exhaled mainstream smoke from the smoker. It contains over 4,000 chemicals, at least 43 of which are known human or animal carcinogens. Measuring ETS in the Air and Body Researchers have found that ETS diffuses rapidly through buildings, persists for long periods after smoking ends, and represents one of the largest sources of indoor particle pollution. Certain constituents of tobacco smoke can be found in the body fluids of nonsmokers who were exposed, indicating that they have inhaled and retained ETS. Health Effects of ETS According to the EPA classification of carcinogens, ETS is classified as a Group A Carcinogen. Group A Carcinogens are agents known to cause cancer in humans. ETS exposure is associated with respiratory problems and an increased frequency of ear infections in young children. ETS may aggravate the conditions of people with existing heart and respiratory disease. Since there is no established health-based threshold for exposure to ETS, and since EPA generally does not recognize either a no-effect or safe level for cancer causing agents, the Agency recommends that involuntary nonsmoker exposure to ETS be eliminated wherever possible. How Big is the Risk from ETS? The number of ETS-attributed lung cancer deaths in US. never-smoking adults is approximately 2,500 annually. The excess number of E'IS-related deaths in former smokers is estimated at about 1,300 annually. Reducing Exposure to ETS Nonsmokers' ETS exposure can be eliminated by: creating enclosed, separately ventilated smoking rooms with direct external exhaust, or prohibiting smoking indoors. PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 3

ETS exposure can be reduced through a number of techniques. These include: creating separate walled areas for smokers and nonsmokers with a shared ventilation system, creating separate unwalled areas for smokers and nonsmokers, air cleaning, air washing and time separating smokers and nonsmokers. The effectiveness of each of these techniques in reducing ETS varies. Regulating Smoking and ETS The number of communities with legislation restricting smoking jumped from 90 in 1985 to 450 in 1989. Most ordinances give higher priority to protecting nonsmokers from environmental tobacco smoke over smokers' preference to smoke. Developing Effective Smoking Policies To succeed, smoking policies need the support of top management. Policies should be developed with employee and labor union input. Whenever smoking policies are introduced, smoking cessation programs should be made available to employees who want to quit. Cost Savings Related to ETS Reduction Organizations that have implemented policies that restrict or eliminate ETS-exposure report some cost savings. Public Attitudes Toward ETS 86% of all Americans (smokers and non-smokers) believe ETS is dangerous to their health. 69% of all Americans (smokers and non-smokers) are annoyed by ETS. 77% of all Americans (smokers and non-smokers) believe that smokers should not smoke in the presence of non-smokers. 4 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE

Recommendations ' Based on the significant health risks associated with ETS, organizations should, wherever possible, eliminate involuntary exposure to ETS at work. Involuntary exposure to ETS can be eliminated by creating enclosed, separately ventilated smoking rooms with direct external exhaust, or by prohibiting smoking indoors. Whenever smoking restrictions are introduced, smoking cessation programs should be made available to employee& Employees and labor unions should be involved in the development of smoking control policies in the workplace. IN PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 5