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SHOOK,HARDY&BACON REPORT ON RECENT ETS AND IAQ DEVELOPMENTS May 14, 1993 SHB

REPORT ON' RECENT ETS AND IAQ DEVELOPMENTS - IN THIS ISSUE - IN THE UNITED STATES REGULATORY AND LEGISLATIVE MATTERS • IAQ bill is introduced in House of Repre- sentatives, p. 1. • OSHA rulemaking options paper nears completion, p. 2. ETS-RELATED LITIGATION AGAINST CIGARETTE MANUFACTURERS • Lorillard's motion for sanctions is granted in Broin, p. 5. • Dismissal order is entered in Zwillmart, p. 5. ETS/IAQ LITIGATION NOT INVOLVING CIGARETTE MANUFACTURERS • Texas attorney general wants to know about fast-food chain's smoking policy, In re: Whazaburger, p. 6. • Texas woman sues Ft. Worth jazz club under ADA, p. 6. • Bahura trial is postponed, p. 6. LEGAL ISSUES AND DEVELOPMENTS • IAQ publication focuses April issue on ETS litigation, p. 8. • BOMA urges smoking bans at ADA semi- nar, p. 9. OTHER' DEVELOPMENTS • Antismoking coalition in Los Angeles organize "Clean Indoor Air Week," p. 9. ISSUE 47 SCIENTIFICITECHNICAL ITEMS •"The Etiology of Lung Cancer," p. 10. •"Parental Smoking and Risk of Childhood Brain Tumors," p. 12. •"Smoking and the Sudden Infant Death Syndrome," p. 12. IN EUROPE & AROUND THE WORLD REGULATORY AND LEGISLATIVE MATTERS • Legislative activity in Australia, Austria and Ireland, p. 13. ETS/IAQ LITIGATION NOT INVOLVING CIGARETTE MANUFACTURERS • Interlocutory default judgment against the defense is lifted in Mansfieg p. 14. OTHER DEVELOPMENTS • Australian survey indicates 77 percent of top companies have smoking policies, p. 15. • Canadian carpet industry will voluntarily test carpets for VOC emissions, p. 15. • WHO discusses ETS during their 46th World Health Assembly, p. 16. MEDIA COVERAGE "Tobacco Smoking in Aircrafr-A Fog of Legal Rhetoric," p. 16.

- TABLE OF CONTENTS - Issue 47 May 14, 1993 IN THE UNITED STATES REGULATORY AND LEGISLATIVE MATTERS U.S. CONGRESS [1] Indoor Air Quality Act Introduced in House ...........................................................................1 [2] Smoking Accommodation Policy Takes Effect in House Office Buildings ............................... 1 U.S. ENVIRONMENTAL PROTECTION AGENCY (EPA) [3] Hearings on Risk Assessment Bill Expected .............................................................................1 [4] Senate Approves Measure to Elevate EPA to Cabinet Level Status ...........................................2 U:S. OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) [5] OSHA Nears Completion of IAQ Rulemaking Options Report ..............................................2 [6] OSHA Revising IAQ Compliance Notice ................................................................................2 [7] Labor Secretary Testifies About OSHA Reform Legislation .....................................................3 [8] ETS-Relared State and Local Legislation..................................................................................3 [9] IAQ Related State and Local Legislation ..................................................................................4 ETS-RELATED LITIGATION AGAINST CIGARETTE MANUFACTURERS [10] Blanchard Hearing on Defendants' Venue Motions Approaches ............................................4 [11] Broirz Lorillard's Motion for Sanctions Granted .....................................................................5 [12] Butler. Dean Butler's Deposition Scheduled ...........................................................................5 [13] ZwiUman: Dismissal Order Entered ........................................................................................5 ETS/IAQ LITIGATION NOT INVOLVING CIGARETTE MANUFACTURERS RESTAURANTS: DECEPTIVE TRADE PRACTICES [14] In rr.• Whataburgrr, Inc. (District Court, Corpus Christi, Texas)' (filed April I 1993)' .................6 AMEwcANs vcnrH DIswBILInEs Acr (ADA) [15] Emery v. Caravan ofDrrams (U.S. Department of Justice) (filed April' 12, 1993)-.--••••.-•••-•••••-•6 PRISONER CASE [16] Blackwelt v. Sheahan. 1993 U.S. Dist. I.F3QS 5650 (UiS. District Court, North District, Illinois, Eastern Division) (decided April 26, 1993) .................................................................6 IAQ-SICK BUILDING SYNDROME [17) Bahtara v. Sb'Wlnvtstors (Superior Court, District of Columbia) (filed September 14, 1990) ..6 PUBLIC PLACES: SEPARATION OF POWFRS [18] Brammer v. Branssad (District Court, Polk County, Iowa) (decided'April 2. 1993) .................6 PUBLIC PIACES: VALIDITY OF SMOKING RESTRICTIONS [19] Operation Badlaw. Inc. v. Licking County General Health Dutrict Board of Health, 1993 U.S. App. LEJQS 8685, (U.S. Court of Appeals, Sixth Circuit) (decided April 13, 1993) ..•..-••.--.---.7 WORIQ'LACE: IAQ/SICK BUILDING SYNDROME [201 Lazarus v. Voith dMacTavitht Karo/] v. Voitb crMacTavirh (Philadelphia County Court of Common Pleas, Pennsylvania) (filed April 1993) .....................................................................7 WoItKPIACE: DISABILITY BENEFTrs [21] Donato v. Metropolitan Lifr Insurance Co., 1993 U.S. Dist. LEXIS 5780 (U.S. District Court. Northern District, Illinois, Eastern Division) (decided April 30, 1993) ........................7 WORIrnrwCE: WORKERS' COMPENSATION [22] Ragle v. State Farm Fire & Casualty Co., 1992 WL 471862 (Alaska Workers' Compensation Board) (decided September 24, 1992) .....................................................................................7 WORKPLACE: COLI.ECTIVE BARGAINING [23] Williams Air Force Base, Ariz, and American Federation of Governmrnt Employees Local 1776. Case No. SA-CA-20302 (Federal Labor Relations Authority) ! (decided April 30, 1993) ...........8 [24] Hi-Ttch Cable Corp: and International Brotherhood ofE/tctrical Workers, Local Union No. 1510,1992 WL 296023 (National Labor Relations Board) (decided September 30, 1992) .....8 LEGAL ISSUES AND DEVELOPMENTS [25] Indoor Pollution Newsletter Features ETS Litigation .............................................................. 8 [26] Insurers Recommend LAQ Inspections ....................................................................................9 [27] BOMA Advises Building Owners to Ban Smoking .................................................................• 9

Contents Continued, Issue 47 OTHER DEVELOPMENTS [281 Division of Publishing House Issues Special Report on ETS ....................................................9 [29] Antismoking Coalition Organizes Clean Indoor Air Week ...................................................:..9 [30] Pizza Hut to Test Smoking Ban .............................................................................................10 MEDIA COVERAGE [31] "Separating Smokers Creates Growing Issue in Restaurants," C. Cambareri, Capital District Business Review, March 29,1993 ...........................................................................................10 SCIENTIFIC/TECHNICAL ITEMS LUNG CANCER [32] "The Etiology of Lung Cancer." D.G. Davila and D.E. Williams, Mayo Clinic Proceedings 68: 170-182, 1993 [See Appendix A] ..................................................................................10 [33] "Implications for Disease Misclassification in Epidemiological Studies of Lung Cancer Risk for Nonsmokers Exposed to Environmental Tobacco Smoke," A.W. Katunstein, Environment International 19: 211-212, 1993 [See Appendix A] ...........................................10 [34] Letters to the Editor Regarding "Environmental Tobacco Smoke and Lung Cancer Risk in Non-smoking Women," H.G. Stockwell, A.L. Goldman, G.H. Lyman, C.L Noss, A.W. Armstrong, P.A. Pinkham, E.C. Candelora, and M.R. Brusa, Journal ofrhe National Cancer Inrtiture 84(18): 1417-1422, 1992 ........................................................................................10 CARDIOVASCULAR ISSUES [35] "Carbon Monoxide and Cardiovascular Disease: An Analysis of the Weight of Evidence," J.H. Mcnncar, Rrgulatory Toxicolody and Pharmacology 17: 77-84, 1993 [See Appendix A] ....................................................................................... 11 ........................... RESPIRATORY DISEASES AND CONDITIONS - CHILDREN [36] "Child Day Care, Smoking by Caregivers, and Lower Respiratory Tract Illness in the First 3 Years of Life," C.J. Holberg, A.L. Wright, F.D. Martinez, W.J. Morgan, L.M. Taussig, and Group Health Medical Associates, Pcdiatrics 91(5): 885-892, 1993 [See Appendix A] .................................................................................................... ...............11 [37] "Risk Factors for Developing Wheezing and Asthma in Childhood." W.J. Morgan and F.D. Martinez, Pediatric Clinirt ofNorth America 39(6): 1185-1203, 1992 [See Appendix A] .................................................................................................... ..............12 OTHER CANCER [38] "Risk Factors for Renal Cell Carcinoma: Results of a Population-Based Case-Control Study," N. Kreiger, L.D. Marrett, L. Dodds, S. Hilditch, and G.A. Darlington, Cancer Causes and Conrrol4: 101-110. 1993 [See Appendix A] .........................................................................12 [39], "Parental Smoking and Risk ofChildhood Brain Tumors," E.B. Gold, A. Leviton„R. Lopez, F.H. Gita, E.T. Hedley-Whyte, L.N. Kolonel, J.L. Lyon, G.M. Swanson, N.S. Weiss, D. West, C. Aschenbrencr, and D.F. Austin, American journal ofEpidrmiology 137(6): 620-628, 1993 [See Appendix A] .........................................................................................12 OTHER HEALTH ISSUES [40] "Effects of Maternal Smoking Upon Neuropsychological Development in Early Childhood: Importance of Taking Account of Social and Environmental Factors," P.A. Baghurst, S.L. Tong, A. Woodward, and A J. MeMiehael. Paediatric and Perirutal Epidrmiology 6: 403-415, 1992 [See Appendix A] ..........................................................................................12 [41] "Smoking and the Sudden Infant Death Syndrome," E.A. Mitchell; R.P.K. Ford, A.W. Stewart. Bj. Taylor, D.M.O. Becroft, J.M.D. Thompson, R. Scragg, I.B. Hassall, D.M.J. Barry, E.M. Allen, and A.P. Roberts, Pediatrics 92(5): 893-896, 1993 [See Appendix A) ....... 12 [42] "Smoking, Passive Smoking and Smelli° P. Hepper, Medical Sciencr Research 20: 265-266, 1992 [See Appendix A] .................................................................................................... ......12 ETS EXPOSURE AND MONITORING [43] "Toxicology of Environmental Tobacco Smoke," M.J. Reasor. In: Toxicology of Combustion Products. L. Manzo and D.F. Weetman (eds.). Pavia, Fondazione Clinica drllavoro, 71-76, 1992 [Scc Appcndix A] .................................................................................................... ......13

Contents Continued, Issue 47 INDOOR AIR QUALITY [44] "Priority Among Air Pollution Factors For Preventing Chronic Obstructive Pulmonary Disease in Shanghai,"' X. Tao, Cj. Hong, S. Yu, B. Chen, H. Zhu, and M. Yang, The Science ofthe Total Environment 127: 57-67, 1992 [See Appendix A] ...................................13 [45] "Emissions of Volktile Organic Compounds from New Carpets Measured in a Large-Scale Environmental Chamber," A.T. Hodgson, J.D. Wooley, and J.M. Daisey, Journal oftht Air and Warte Management Association 43: 316-324„ 1993 [See Appendix A] ...................... 13 SMOKING POLICIES AND RELATED ISSUES [46] "C1ean Indoor Air Legislation, Taxation, and Smoking Behaviour in the United States: An Ecological Analysis,"'S.L. Emont, W.S. Choi, T.E. Novotny, and G.A. Giovino, Tobacco Control2: 13-17. 1992 [See Appendix A] ................................................................13 IN EUROPE & AROUND THE WORLD REGULATORY AND LEGISLATIVE MATTERS AusTRALiA [47] Health Authority Considers Restaurant Smoking Ban ........................................................... 13 [48] Cab Drivers Respond to Taxi Smoking Ban ..........................................................................13 AusTRiA [49] Shop Owners Protest Government Plans to Restrict Smoking ...............................................14 IRELAND [50] Dublin Corporation Considers Workplace Smoking Policy ................................................... 14 ETS/IAQ LITIGATION NOT INVOLVING CIGARETTE MANUFACTURERS AusrxwLCA [51] Mansfield v. The Herald etr Weekly Times Ltd. (Victoria County Court, Melbourne) (filed November 19, 1992) .................................................................................................... .........14 LEGAL ISSUES AND DEVELOPMENTS StNGAPORE [52] Ministry of Health Conducts Workplace Smoking Seminar .................................................. 14 OTHER DEVELOPMENTS AvsrRALIA [53] Author Addresses Scare Tactics Intended to Modify Behavior ............................................... 14 [54] Doctors Disagree with Studies on Asthma and Pollution ....................................................... 15 [55] Survey Reveals 77 Percent of Top Companies Have Smoking Policiu ................................... 15 CANADA [56] Canadian Carpet Industry Adopts Voluntary Testing Program .............................................. 15 HONG KONG [57] Survey Reveals Support for Smoking Bans .............................................................................15 SINGAPORE [58) Survey Finds Sick Buildings ...................................................................................................1 5 UNITLD KINGDOM [591 BAT Publishes Brochure on "Social Engineering" .................................................................15 WORLD HFALTH ORGANIZATION (WHO) [60] WHO Meets In Geneva for 46th World Health Assembly .................................................... 16 MEDIA COVERAGE CANADA [61] "Tobacco Smoking in Aircraft - A Fog of Legal'Rhetoric?," R.LR. Abeyratne, Air dSpacrlaw, No. 2 1993 .................................................................................................... ........................16 APPENDIX A .................................................................................................... .................................Arricle Summaries

MAY 14, 1993 1 REPORT ON RECENT ETS AND IAQ DEVELOPMENTS IN THE UNITED STATES REGULATORY AND LEGISLATIVE MATTERS U.S. CONGRESS Kennedy introduced similar IAQ legislation in past sessions of Congress that failed to gain passage. Provi- sions of the prior bills, which some believed blocked earlier passage, would have required an OSHA ventila- tion-based standard as well as mandatory, product- emission labelling. Those provisions were dropped fromiH.R 1'930.. [1] Indoor Air Quality Act Introduced in House On April 29, 1993, Representative Joseph Kennedy (D-Mass.) : introduced the House version of the Indoor Air Quality Act of 1993 (H.R. 1930). Co-sponsored by 23 other, mostly Democratic, House members, the measure would' authorize $47 million in spending over the next five years to fund indoor air research, a federal indoor air response plan, and state matching grants for devising local response plans. The House bill does not explicitly mention ETS, and Representative Kennedy did not cite the EPA Risk Assessment on ETS in his remarks at the time the bill was introduced. The bill, in many respects, is similar to the legislation introduced in the Senate in March 1993 (S. 656), in that its focus is on research into the causes of poor indoor air quality, methods of mitigation, upon coordination of federal and state activities regarding the improvement of indoor air quality. Also, like its Senate companion, the House bill would require an assessment of the role of ventilation in mitigating IAQ problems, but does not establish ventilation standards. The bill would not preempt any other federal or state law incorporating more restrictive compliance standards. Unlike its Senate counterpart, the Kennedy bill does not require publication of a list designating contami- nants known to have an adverse impact on human health. It does, however, require the EPA to publish "indoor air contaminant health advisories" on a prescribed schedule. The bill has been referred to three House committees: Education and Labor, Energy and Commerce; and Science, Space and Technology. At the time this Report was prepared, no committee action had been scheduled on the measure. [2] Smoking Accommodation Policy Takes Effect in House Office Buildings On May 7, 1993, the House Office Building Com- mission announced its policy for smoking restrictions in public areas of all House office buildings would take effect immediately: Smoking will only be permitted in designated areas. Speaker of the House Thomas Foley (D-Wash.) directed that a similar policy be imple- mented for the House side of the Capitol. In areas assigned to House members, committees and support offices, smoking policies are to be determined by each member, committee chair and support office head. The Capitol Architect has been directed to develop a plan for the Office Building Commission's approval designating public areas where smoking will be permitted. U.S. ENVIRONMENTAL PROTECTION AGENCY (EPA) [3] Hearings on Risk Assessment Bill Expected The Senate Environment & Public Works Commit- tee is reportedly expected to hold hearings in May or June on a bill that would coordinate the development and implementation of environmental policies at EPA. The bill, S: 110, was introduced in January 1993 by New York Senator Patrick Moynihan (D). See issue 41 of this Report, February 19, 1993. The measure would establish committees that would attempt to formalize risk assessment by ranking relative risks and by estimating the quantitative benefits of reducing risks. Critics have warned that current scientific knowledge is insufficient to support such an

2 effort. Supporters, howevery contend that the matter must be addressed regardless of its complexity. According to a press report, Representative Dick Zimmer (R-NJ) is considering introducing a compan- ion bill in the House. See Inside EPA, April! 30, 1993. [4] Senate Approves Measure to Elevate EPA to Cabinet Level Status On May 4, 1993, the Senate voted 79-15 to approve a bill which would give the EPA a seat in the President's Cabinet (S. 171). The Senate measure would establish a new Department of Environmental Protection and would permit regional offices to continue as they are presently set up. The bill would abolish tlie'White House Counsel on Environmental Quality. Among the amendments reportedly added to the bill is a provision requiring a risk assessment and cost benefit analysis of each final regulation. See BNA National Environment Daily, May 5, 1993. Meanwhile, the House has apparently begun to conduct hearings on its draft EPA bill. Critics of the agency, such as Representatives John Dingell (D- Mich.), Michael Synar (D-Okla.), and Henry Waxman (D-Calif.), are reportedly seeking major reform of the EPA's management, contracting, procurement, science and enforcement policies before they will agree to * elevate the agenry to Cabinet level. Waxman report- edly opposes the cost benefit analysis that was added to the Senate measure by amendment. During subcom- mittee hearings, Dingell apparently stressed the need for truthful science, called for an end to "cooked" studies at the agency, and criticized the agency's use of contractors. According to EPA Administrator Carol Browner, the agency supports much of the House draft bill, which is said to contain many of Dingell's suggestions, indud- ing changes in contracting practices and peer review of EPA analyses and reports. See BNA National Environ- ment Daily, May 10, 1993. U.S. OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA) [5] OSHA Nears Completion of IAQ Rulemaking Options Report According to Charles Adkins, director of OSHA's health standards program, a policy options report ETS/IAQ REPORT, ISSUE 47 offering several approaches for OSHA to take in promulgating an IAQ rulemaking is nearing comple- tion, and the next agency administrator is expected to make a decision on how to proceed by the summer. The Clinton administration has yet to name an administrators but the top candidate for the position, former director of the Washington Department of Labor and Industries John Dear, has apparently been hired as an OSHA consultant. The options paper is expected to offer two major policy options, i.e., either a wide-scale IAQ rule to address ventilation concerns and various contaminants or a separate rule addressing only ETS. Adkins is quoted as saying, "We're looking at a period of six months after a decision is made [by the OSHA admin- istrator] before the rule could be proposed." Adkins further stated that job stress and other "psychosocial factors" will not be addressed in OSHA's efforts to develop an IAQ rule for the workplace. Some studies have indicated that psychosocial factors are at least partly responsible for generating IAQ complaints. According to an OSHA industrial hygienist, a preliminary assessment of the 1200 comments submit- ted in response to OSHA's request for information on indoor air has revealed substantial public support for (i) performance-based ventilation standards giving employers flexibility to achieve compliance; (ii) mandatory training for employees who maintain or operate HVAC systems; and (iii) control of the use and introduction of contaminants, solvents and gases in the workplace. A more thorough analysis of the public comments is apparently due this summer. See BNA Occupational Safety d Health Reporter, April 28, 1993. [6] OSHA Revising IAQ Compliance Notice According to a press report, OSHA is currently revising a compliance notice for agency inspectors to continue to conduct workplace IAQ investigations. The compliance notice being used by inspectors evidently expired in October 1991. Even though OSHA has no workplace IAQ regulations, inspectors have reportedly been instructed to respond to em- ployee IAQ complaints and may cite employers under other related standards. According to an OSHA directive on the issue, compliance officers cannot cite employers under the general duty clause of the Occu- pational Safety and Health Act because (i) most

MAY 14, 1993 industry consensus standards are derived from a combined consideration of comfort and adverse effects and (ii) there are no formal occupational exposure guidelines addressing ETS. See BNA Occupational Safety ti'Health Reporter, Apri128, 1993. [7] Labor Secretary Testifies About OSHA Reform Legislation During an Apri128 hearing conducted by the House Education & Labor Committee, Secretary of Labor Robert Reich discussed the issue of proposed OSHA reform. The subject of the hearing was H.R. 1280, see issue 43 of this Report, March 19, 1993, but Reich did not address his comments to specific provisions of the reform measure, indicating that the new Administra- tion has not yet had an opportunity to fully consider the bill. Reich did not discuss indoor air quality in his testimony, although several press reports indicated that he did so: See The Houston Chronicle, Apri129, 1993; States News Service, Apri128, 1993. [8] ETS-Related State and Local Legislation •California The Governmental Organization Committee has approved a bill that would enact limited statewide smoking restrictions, but would prohibit many cities from adopting tougher anti-smoking laws in the future (A.B. 996): Cities and communities that already have tougher restrictions would be allowed to keep them. The bill is controversial because it supposedly threatens A.B. 13, a bill that has been approved by the Labor and Employment Committee and would prohibit smoking in enclosed workplaces throughout the state. Both bills are now pending in the Assembly Ways and Means Committee. Bill' 996 could generally ban smoking in restaurants, but would allow a restaurant to set aside up to 30 percent of its area as a smoking section if ventilation meets ASHRAE Standard 62-1989. The restaurant would have to display signs notifying patrons that smoking is allowed in specified areas. The bill would also restrict smoking in workplaces and other indoor public areas. The bill has been criticized as "a tobacco industry Trojan horse. It has the exterior appearance of restricting smoking, yet upon examination it is a ploy by the tobacco industry to stop the momentum for the total workplace smoking ban." See BNA California - 3 Safety [r Health Report, Apri126, 1993, The United Press Internationa4 April 27, 1993, Sacramento Bee, April 28, 1993, and Los Angeles Times, Apri130, 1993. •Local Governments in Georgia According to press reports, Fulton County Commission- ers passed an ordinance Apri121, 1993, banning smok- ing in most public places. The Clean Indoor Air Ordi- nance goes into effect May 20, 1993, and prohibits smoking in elevators, hallways, indoor sports arenas, and health care facilities. Employers must create a smoke-free workplace; however, they are not required to spend any money to make structural changes. Restaurants must set aside at least 50 percent of their dining areas for smokers. Fulton's ordinance was patterned on a DeKalb County law passed last year, but Fulton's law applies to all cities in the county, induding Atlanta, while the DeKalb County Legislation applies only to unincorporated areas of the county. The Fulton law exempts state-owned or run buildings, such as jails, the Capitol or the Georgia Dome, and it excludes bars, hotel rooms and cigarette shops. Hartsfield International Airport main terminal is in Fulton County and will fall under the ordinance; however, the concourses do not because they are in Clayton County. A spokesman for the Tobacco Institute was quoted to say that the ordinance "strikes a balance." See The Atlanta Journal and Constitution, April 21, April 22, and April 24, 1993. •Hawaii Governor John Waihee (D) has signed into law a bill that prohibits smoking in all group child care homes, group child care centers and family child care homes during their hours of operation. See S.B. 831, 17th Legislative Session - 1st Reg. Sess. (1993). •Local Government in Massachusetts On May 5, 1993, the Boston City Council approved an ordinance that requires employers to formulate policies on workplace smoking. The measure also prohibits employers from regulating off-the-job use of tobacco by employees. Dropped from the final version of the measure was a section that would have required giving a preference to nonsmokers in making accommodations between smokers and nonsmokers. See Daily Labor Report, May 7, 1993. On April 27, 1993, the Norwell Board' of Health reportedly proposed a ban on smoking in public places and workplaces that employ more than three people. Restaurants are exempt as long as they provide a separate

4 ventilated area for smokers. Voters accepted the measure by a 120-101 vote, according to officials. The president of the Norwell Chamber of Commerce was reported to say, "It's government intrusion in small business." See The Boston Globe, May 2, 1993. •New York According to a news report, Governor Mario Cuomo (D) proposed legislation April 14 that would toughen existing smoking restrictions by, among other things, limiting smoking in the workplace to separately- endosed, designated rooms. The measure-would also require that restaurants, bowling alleys and bingo halls have separate enclosed areas where smoking is allowed. Smoking would be prohibited in fast-food restaurants and other eating establishments that seat fewer than 50 people and don't have a liquor license. Smoking also would be banned in youth centers, child care facilities, community residences, public institutions for children, and residential treatment facilities for children. See BNA Product Liability Daily, May 3, 1993, Gannet News Servict, May 3, 1993, and National Public Radio, May 3, 1993. >New Yak IAQ Bils, ftem 9. •Vermont According to press reports, the legislature passed a bill on April 27, 1993, that prohibits smoking in restau- rants, motels, banks and stores. Governor Howard Dean (D) reportedly has promised to sign the bill after the legislative session ends. If Governor Dean signs the bill, it,will take effect in two stages. On July 1, 1993, smoking will be prohib- ited in all public buildings, as well as some private buildings that are open to the public, such as libraries, stores, waiting rooms and video arcades. On July 1, 1995, smoking will be prohibited in restaurants, bars, hotels and motels, with an exception for establishments that hold a cabaret license, because they earn more than half their revenue from the sale of alcohol or entertainment. The bill's sponsor was reported to say that the bill was prompted in part by concern over the EPA Risk Assessment on ETS. However, one legislator who opposed the bill was quoted as saying, "The EPA findings were based on prolonged in-home exposure to smoking. There's no evidence about the health risks from occasional, casual exposure." See The Associatad Press, The New York Times, and Miami Herald May 2, 1993. ETSIIAQ REPORT, ISSUE 47 [9] IAQ Related State and Local Legislation •New York Bills are pending in both chambers of the New York legislature that would require building owners to develop a"plan°° for heating, ventilation and air conditioning and to maintain a log of IAQ complaints (S.B. 4594 and A.B. 3603). The HVAC "plan" would indude a description of the building's HVAC system, its operation, and procedures and schedules for mainte- nance. The plan also would describe ways to minimize contaminant exposure and adverse effects on building occupants during or after renovation or construction. Most of the bills' provisions are similar, but there are some differences. Only A.B. 3603 requires building owners to keep logs of complaints and maintenance records and to prepare reports responsive to com- plaints. Only S.B. 4594 specifically requires that the HVAC plan comply with~ standards established in ASHRAE Standard 62-1989 "or subsequent, updated standards." S.B. 4594 also would require that the HVAC plan be prepared by an engineer licensed by New York State. SceA.B. 3603 and S.B. 4594, 215th: General Assembly - 1st Reg. Sess. (1993). ETS-RELATED LITIGATION AGAINST CIGARETTE MANUFACTURERS [110] Blanchard Hearing on Defendants' Venue Motions Approaches A hearing is still scheduled for May 20, 1993, on defendants' motions to transfer venue and motions to strike. The motions have been pending since January. Three of the 14 plaintiffs in this case presently allege injury from exposure to ETS. Raye Blanchard and Tamara Reed, mother and daughter, both claim damages for unspecified "illness and disease" allegedly resulting from exposure to the ETS from cigarettes smoked by Raye's deceased husband, Thomas, and by Raye herself, who daims she smoked "for about ten years." The third ETS plaintiff, Pamela Kastrin Stephens, daims unspecified "lung and respiratory diseases" allegedly caused by exposure to the ETS from the cigarettes smoked by her deceased father. The named defendants are purported to be the six major U.S. cigarette manufacturers, The Tobacco Institute,

MAY 14, 1993 the Council for Tobacco Research, and a number of wholesalers and retailers. Blanchard, et a1 v. RJ. Reynolds Tobacco Company, et al. (District Court, Galveston County, Texas) (filed July 31, 1992). [11] Broin: Lorillard's Motion for Sanctions Granted At a hearing on May 11, 1993, Lorillard's renewed motion for sanctions was granted as to the claims filed by plaintiff Bonita Baker. Judge Robert Kaye also said he would dismiss plaintiff Terry Casto, a subject of the sanctions motion who has asked that her daims be dismissed. In the motion for sanctions, Lorillard sought dis- missal of the claims of those plaintiffs who had not fully responded to Lorillard's discovery requests. When the motion was filed, it was directed to eight plaintiffs, but six of them (all except Baker and Casto) filed responses to the discovery requests prior to the May 11 hearing. The depositions of plaintiffs Gary Hayes and' Valerie Gibson have been re-noticed by defendants for June 2 and June 16. They will be the first plaintiffs to be deposed. A hearing is scheduled before the trial court for May 17 on motions to dismiss plaintiffs' second amended complaint that have been filed by The Tobacco Institute, the Council for Tobacco Research, the Tobacco Merchants Association, and the Florida Tobacco and Candy Association. At issue in this case are the claims of flight attendants allegedly injured by occupational exposure to ETS. Following the dismissals noted above, the claims of 28 flight attendants remain in the case. In addition, the husband of one of the flight attendants claims loss of consortium. The attendants named as plaintiffs purport to represent a class of approximately 60,000 other attendants. Injuries alleged by the putative dass representatives include lung cancer, breast cancer and unspecified respiratory ailments. Plaintiffs further allege that occupational exposure to ETS on board aircraft causes at least 22 diseases and a reasonable fear of contracting such diseases. The defendants are purported to be the six major U.S. cigarette manufacturers (plus related entities), UST, Inc., United States Tobacco Company, Dosal Tobacco Corp., the Council for Tobacco Research, The Tobacco Institute, and three trade 5 associations. Broin, et al., v. Philip Morris, et al. (Circuit Court, Dade County, Florida) (filed October 31, 1991). [12] Butler. Dean Butler's Deposition Scheduled The deposition of plaintiff Dean Butler, wife of . plaintiff Burl Butler, is scheduled to be taken on May 19 and 20, 1993. Mrs. Butler alleges loss of consortium as a result of Mr. Butler's lung cancer. Mr. Butler claims his lung cancer was caused by exposure to ETS in the barbershop he owned and operated for approxi- mately 30 years. A status hearing is still scheduled'for May 28 on plaintiffs' various motions, including their motion for a discovery conference, their motion for leave to file a second amended complaint, and several motions relating to discovery matters. It is possible that a trial date will be set at this hearing. The defendants in this case consist of the six major U.S. cigarette manufacturers and several local retailers. Butler v. RJ. Rtynolds Tobacco Company, et al (Circuit Court, Hinds County, Mississippi) (filed October 21, 1992). [13] Zwillman: Dismissal Order Entered On April 21, 1993, the court formally granted plaintifl's request to dismiss this case with prejudice. Plaintiff had asked that the case be dismissed when he was contacted by telephone during a status conference on April' 16. Zwillman was originally a smoking-and-health case fded' pro se by Wolf Zwillman for himself and as the personal representative of his wife, Marjorie Zwillman, a smoker who allegedly died of lung cancer. Claims that Mrs. Zwillman's injuries were also caused by exposure to ETS were added in an amended complaint. Brooke Group, Ltd., and The American Tobacco Company were the only defendants at the time the case was dismissed. Brooke Group is the successor to Liggett and Myers. Zwillman v. Brooke Group Limiud, et aL (U.S. District Court, New Jersey) (filed February 15, 1991; second amended complaint adding ETS claims filed February 13, 1992).

6 ETS/IAQ LITIGATION NOT INVOLVING CIGARETTE MANUFACTURERS RESTAURANTS: DECEPTIVE TRADE PRACTICES [14] In re: Whataburger, Inc. (District Court, Corpus Christi, Texas) (filed April 1993) Texas Attorney General Dan Morales has reportedly filed a suit against Whataburger, Inc., seeking to force the company to answer 23 questions about its restau- rant smoking policies. Apparently, the attorney general's office wants restaurants to warn their custom- ers that nonsmoking sections may not be smoke free if the ventilation for those areas is not separate from smoking area ventilation. According to Morales, failure to so warn is a violation of deceptive trade laws. See The Houston Chronicle, April 25, 1993. AMERICANS WITH DISABILITIES ACT (ADA) [15] Emery v. Caravan ofDreams (U.S. Department of Justice) (filed April 12, 1993) A woman who allegedly suffers from the degenerative lung disease cystic fibrosis has reportedly filed an ADA complaint with the Department of Justice to force a Fort Worth jazz dub to ban smoking as an accommo- dation of her disability. She daims ETS exposure "severely reduces" her lung function. According to a press report, the complainant, Diane Emery, is repre- senting herself and intends to rely upon the EPA Risk Assessment on ETS to support her claim. The jazz club, Caravan of Dreams, reportedly does have a nonsmoking section in the front row, and the club is considering expanding its nonsmoking section. According to the club's president, smokers have complained when performers insist that patrons refrain from smoking and that in any event, the club is well ventilated. He has indicated that Emery's discrimina- tion complaint is being reviewed and will be answered by July 1. See The Dallas Morning News, May 1, 1993. PRISONER CASE [16] Blackwell v. Sheaban,1993 U.S. Dist. LEXIS 5650 (U.S. District Court, North District, Illinois, Eastern Division) (decided April 26, 1993) A U.S. District Court judge has refused at this time to certify as a class action a pro se prisoner's complaint ETSIIAQREPORT, ISSUE 47 alleging that prison officials at the Cook County jail discriminated against a number of inmates by moving them to a nonsmoking maximum security division: The court found that the pro se litigant would be unable to protect the interests of the proposed class. In addition, the court found no legal merit to the prisoner's daim of discrimination on the ground that there is no constitutional right to smoke and that loss of smoking privileges does not constitute the infliction of cruel and unusual punishment. The complaint also alleged, among other matters, that the jail's ventilation is poor. As to this claim, the court gave the prisoner 30 days to amend his complaint to state "how his claim of poor ventilation rises to more than mere discomfort." If the complaint as amended appears to have a "substantial factuai basis demonstrat- ing potential legal merit," the court will consider appointing counsel who can determine whether it would be appropriate to seek certification of a class. jAQ SICK BUILDING SYNDROME [17] Bahura v. SEWlnvestors (Superior Court, District of Columbia) (filed September 14, 1990) The trial of this case has been continued from June 28, 1993, and is now scheduled to begin on October 25. A pretrial conference is set for October 1. The case involves employees of EPA who have sued various parties involved in renovation of the Waterside Mall complex that serves as EPA's national headquarters. Plaintiffs allege health problems due to poor IAQ. PUBLIC PLACES: SEPARATION OF POWERS [18] Brammer v. Branstad (District Court, Polk County, Iowa) (decided April 2, 1993) A district court judge has dismissed the suit filed by an Iowa legislator who sought a smoking ban in the Statehouse, saying it was an internal matter for the legislature to decide. Attached to Representative Philip Branuner's complaint was an opinion by the Iowa Attorney General, which asserted that state law would prohibit smoking in the Statehouse unless smoking areas were designated therein. The Chairperson of the Legislative Council had "unilaterally designated the rotunda and legislative

MAY 14„ 1993 dining rooms as smoking areas," according to Brammer. He alleged the Chairperson had' acted unlawfullgand without authority in arbitrarily making such designations. Stating that such a designation was a matter of legislative prerogative, the court held'that the issue was not subject to judicial'review. According to press reports, Brammer, an ex-smoker who allegedly suffers from chronic lung disease, has vowed to pursue the matter under the Americans with Disabilities Act. See The Des Moines Register, April 4, 1993. PUBLIC PLACES: VALIDITY OF SMOKING RESTRICTIONS [ 19] Operation Badlaw, Inc v. Licking County General Health District Board of Health, 1993 U.S. App. LEXIS 8685, (U.S. Court of Appeals, Sixth Circuit) (decided April 13, 1993) The Sixth Circuit Court of Appeals has dismissed the daims of a non-profit group which had challenged the constitutionality of regulations limiting smoking in public places and places of employment. Plaintiff Operation Badlaw, Inc., challenged the regulations passed by two Ohio Boards of Health in January 1992 on grounds of equal protection, due process, privacy, commerce dause, and impairment of contract. The court found that none of these rights had been violated and that the regulations had a rational relationship to "the legitimate state purpose of mim- mizing unwanted exposure to second-hand smoke." WORKPLACE: IAQISICK BUILDING SYNDROME [20] Lazarus v. Voith c4'MacTaviA Karoll v. Voith dMarTavish (Philadelphia County Court of Common Pleas, Pennsylvania) (filed April 1993) Two additional plaintiffs have reportedly filed suits against the contractors involved in renovating a library building on the Bryn Mawr College campus near Philadelphia, for injuries allegedly caused by exposure to toxic substances. The contractors were sued in January by college employees Allyn Bensing and Anne Skoogfors. See issue 44 of this Report, April 2, 1993. One of the additional plaintiffs is apparently a student 7 who has also named the college as a defendant. See Indoor Pollution Law Rtpom April 1993. WORKPLACE: DISABILITY BENEFITS. [21] Donato v. Metropolitan Life Insurance Co., 1993 U:S. Dist. I.E3QS 5780 (U.S. District Court, Northern District, Illinois, Eastern Division) (decided April 30, 1993) A U.S. district court has granted a motion for sum- mary judgment filed by an insurer who terminated the disability benefits of a legal secretary who claimed she was disabled by a severe allergic reaction to ETS, walt to-wall carpeting and perfumes. The secretary, Chris- tine Donato, filed this action under the Employee Retirement Income Security Act of 1974 (ERISA), and the court used ERISA's "arbitrary and capricious" standard to uphold the employer's actions. Although Donato's treating physicians had diagnosed a severe and disabling allergic reaction to environmen- tal chemicals, the insurer's medical consulting firm conduded that she was not disabled and that the therapies she was undergoing "are not widely sup- ported by the AMA, the American College of Physi- cians, or recognized medical bodies." The court found that the insurer did not arbitrarily and capriciously terminate Donato's disability benefits and ordered that Donato pay the insurer the $4,640.00 that she had received from the Social Security Administration (SSA). The agreement between Donato and the insurer provided that any benefits paid by the insurer would be reduced by amounts paid or payable to Donato bySSA. WORKPLACE: WORKERS' COMPENSATION [22] Ragle v. State Farm Fire er Casualty Co., 1992 WL 471862 (Alaska Workers' Compensation Board) (decided September 24, 1992) The Alaska Workers' Compensation Board has dismissed a daim for medical costs submitted by a health care provider in a case involving a claim of "systemic immune dysfunction" caused by exposure to mold and other toxins in a "sick building." The claimant in the case, Carol Ragle, is an allergy specialist and nutritional consultant who worked for the health care provider/employer that ultimately provided her

8 diagnosis and prescribed various purgative treatments and injections. In its opinion, the Board details the evidence in the case, which consisted of numerous opinions from medical experts that the daimant's condition has psychological origins. Allergy tests proved negative, and testing conducted' in Ragle's home, car and office showed that the "sanctuary" she found in her home was actually more contaminated with mold than the office in which she worked and which she claimed caused her disability. The health care provider's daim was denied because the Board found that it had actually been withdrawns and the provider was instead seeking payment from Ragle. The Board dedined to rule upon the merits of this claim, but noted that Ragle may not be required to pay for treatment or services if she can establish the existence of a work-related injury. WORKPLACE: COLLECTIVE BARGAINING [23] Willictms Air Force Base, Ariz., and American Federation of Government Employees Local 1776, Case No. SA-CA-20302 (Federal Labor Rela- tions Authority) (decided April 30, 1993) . An administrative law judge has reportedly ruled that Williams Air Force Base violated Tide VII of the Civil Service Reform Act of 1978 by unilaterally dosing a hallway smoking area without offering the union an opportunity to negotiate the issue. According to the judge, dosure of the smoking area forced smokers to use a gazebo that was exposed to 116 degree heat and "hordes of white flies." The employer had argued that the smoking area was closed because it was not prop- erly ventilated, and the cost of upgrading the ventila- tion was not justified due to the planned dosure of the facility some time in 1993. The judge rejected the employer's arguments and ordered the restoration of the hallway smoking area until the obligation to bargain has been compGed with. [24] Hi-Tech Cablr Corp. and Internationrrl Brother- hood ofElectrical Workers, Local Union No. 1510, 1992 WL 296023 (National Labor Relations Board) (decided September 30, 1992) The National Labor Relations Board has determined that an employer was required to submit a change in its ETS/IAQ REPORT, ISSUE 47 workplace smoking policy to collective bargaining. The employer, Hi-Tech Cable Corp., unilaterally adopted a no-smoking policy at its facility and refused to negoti- ate the reasonableness of the rule with the union. The union filed a grievance which was denied, and one employee was issued a written warning for breach of the rule. On appeal, the Board held that the language of the collective bargaining agreement between the parties did not constitute a waiver of the union's statutory right to bargain about the implementation of a work rule. The employer was ordered to bargain over the issue and to remove the written warning from the employee's file. LEGAL ISSUES AND DEVELOPMENTS [25] Indoor Pollution Newsletter Features ETS litigation The April 1993 issue of the Indoor Pollution Law Report is devoted primarily to ETS litigation. Accord- ing to an editor's note, the focus is the result of the EPA's designation of ETS as a "Class A carcinogen." One artide by Edward'Sweda, Jr., a Massachusetts lobbyist for an anti-smoking group, summarizes the cases cunently pending around the nation involving ETS issues. Sweda discusses the litigation filed in Connecticut by the mothers of asthmatic children against fast-food restaurants, Staron v. McDonald's Corporation; the prisoner case recently argued before the U.S. Supreme Court, Helling v. McKinney, the suit filed in Florida by airline flight attendants, Broin v. Philip Morris Companies, Inc.; and the case brought by a Mississippi barber against cigarette manufacturers, Butler v. RJ. Reynolds Tobacco Co.. A sidebar to the article lists the names of the attorneys representing some of the litigants in these cases. Sweda also discusses the EPA Risk Assessment on ETS and states that it will be used to solidify the claims of the plaintiffs in Broin and Butler. According to Sweda, the plaintiffs' attorney in Staron told The New York Times that the risk assessment will provide the "bulk of the medical evidence" for the case, which will be litigated under the Americans with Disabilities Act. Another article in this issue is written by Cynthia Langston-Lott. A former defense attorney, Langston-

MAY 14„1993 Lott is currently an associate in the law firm represent- ing the plaintiffs in the Butler case. She discusses the facts of the case from her perspective and devotes considerable attention to what she characterizes as the tobacco industry's delaying tactics. According to Langston-Lott, the plaintiffs are prepared to meet the challenges of facing well-financed opponents in court and plan to benefit from research and discovery conducted by other law firms in other tobacco litiga- tion. She says, "It is the opinion of the author's firm that the key to tobacco litigation is keeping the court informed of the strategy of delay for which the tobacco industry is renowned in an effort to control such tactics from the onset." See Indoor Pollution Law Repom April 1993. [26] Insurers Recommend IAQ Inspections According to an article appearing in an insurance trade publication, sick building syndrome is linked, among other matters, to ETS and should be a subject of employer concern. The senior vice president and general counsel for the Gulf Insurance Group is quoted in the article and reports that there have been "rashes" of sick building claims in certain buildings within the last six to seven years, and that sick building syndrome can be expensive to employers in terms of health benefits and workers' compensation claims. This attorney further states that the presence of ETS in buildings may form the basis for sick building claims in light of the EPA Risk Assessment on ETS and suggests that companies with sealed windows consider conduct- ing air quality tests to assess other possible sources of sick building complaints. See National Undenuriter, Property & Casualty/Rrsk d~' Benefits Management Edition, April 19, 1993. [27] BOMA Advises Building Owners to Ban Smoking During an Americans with Disabilities Act compli- ance seminar conducted for building owners in Texas, a lobbyist for BOMA International advised participants to attack indoor air problems at the source, such as by prohibiting smoking. The lobbyist cited the New England Journal of Medicine report relating to the relationship between indoor air complaints and increased ventilation. He also reportedly observed that the Department of Justice has handled "thousands of complaints" since the ADA took effect more than a year ago. SeeAustin BusincssJourna4 April 12, 1993. 9 OTHER DEVELOPMENTS [28] Division of Publishing House Issues Special Report on ETS The Bureau of Business Practice (BBP), a Connecti- cut-based division of publisher Simon & Schuster, Inc., has issued a "Special Supplement to Fair Employ- ment Practice Guidelines" that discusses the legal implications of the EPA Risk Assessment on ETS. Although the document contains a disclaimer that the publisher is not engaging in rendering legal advice, BBP condudes that the EPA report "is likely to strengthen the legal position of those individuals who claim they are affected by ETS" and advises employers that they face "serious legal ramifications" if they dismiss the complaints of nonsmokers about workplace ETS exposure. The BBP discusses the respective legal positions of smokers and nonsmokers and addresses the potential for successful workers' compensation claims and for litigation under the Americans with Disabilities Act by those alleging sensitivity to ETS. The document erroneously states that, as of January 1993, 18 states had laws prohibiting discrimination against smokers, but advises employers to check the laws in their state if they have a policy of refusing to hire smokers. A "Special Report" on ETS is being made available, free of charge, to those with BBP accounts, and a toll free telephone number is provided to those interested in reading more about the risk assessment and informa- tion from the Surgeon General, NIOSH, and "leading health and legal experts." According to BBP, the Report further "gives you the facts you need to show people throughout your organization how smoking bans and cessation programs benefit everyone." [29] Antismoking Coalition Organizes Clean Indoor Air Week Groups representing the African American, Asian/ Pacific Islander and Latino communities reportedly urged restaurants and other Los Angeles businesses to ban smoking during Clean Indoor Air Week. The week was scheduled to begin on May 9, 1993, which was Mother's Day. One organizer reportedly said he and the members of his group felt people would be taking their mothers out and that "they would like to take her somewhere clean and smoke free to show her

10 they care." The event reportedly also garnered the support of several Los Angeles City councilpersons. See Los Angeles Times, May 8, 1993. [30] Pizza Hut to Test Smoking Ban Pizza Hut chain restaurants will reportedly begin experimenting with a smoking ban. This according to the CEO of PepsiCo, the chain's corporate owner, who spoke recently about the company's financial picture for 1993. See Reuters, May 5, 1993. MEDIA COVERAGE [31] "Separating Smokers Creates Growing Issue in Restaurants," C. Cambareri, Capital District Business Review, March 29, 1993 This artide discusses efforts that are being taken by restaurateurs in recent years in response to complaints by nonsmokers about ETS in restaurants. Apparently, the move to separately ventilate smoking sections and/ or totally ban smoking has intensified following the January 1993 release of the EPA Risk Assessment on ETS. One restaurant owner observed that smokers generally eat more and drink more than nonsmokers and that banning smoking could have an impact upon a restaurant's bottom line. According to a legislative director for one New York Assemblyman, the EPA designation of ETS as a Group A carcinogen leaves "no scientific dispute" about the issue. SCIENTIFIC/TECHNICAL ITEMS LUNG CANCER (32] "The Etiology of Lung Cancer," D.G: Davila and D.E. Williams, Mayo Clinic Proceedings 68: 170-182, 1993 [See Appendix A] This review artide focuses on a number of factors thought to be associated with lung cancer and also discusses genetic, cellular and molecular aspects of the disease. A section of the anicle is devoted to a discus- sion of the ETS epidemiology; the authors propose ETS/IAQ REPORT, ISSUE 47 that the incidence of lung cancer is "clearly increased" with ETS exposure, but that estimation of the claimed risk is "controversial." [33] "Implications for Disease Misclassification in Epidemiological Studies of Lung Cancer Risk for Nonsmokers Exposed to Environmental To- baoco Smoke," A.W. Katzenstein, Envsromnent Internationa119: 211-212,1993 [See Appendix A] The author of this letter to the editor addresses the 1992 review draft of the EPA Risk Assessment on ETS. He focuses on the lack of "[d]efinitive diagnosis" of primary lung cancer in many of the spousal smoking studies, suggesting that this results in "significant potential for disease misclassification," which could affect the EPA's reported risk estimate. [34] Letters to the Editor Regarding "Environmental Tobacco Smoke and Lung Cancer Risk in Non- smoking Women," H.G. Stockwell, A.L. Goldman, G.H. Lyman, C.I. Nloss, A.W. Armstrong, P.A. Pinkham, E.C. Candelora, and M.R Brusa, Journal of the National Cancer Institute 84(18): 1417-1422, 1992 The Journal of the National Cancer Institute recently published four letters concerning the Stockwell, et al., paper, which reported on a Florida case-control study of household and spousal smoking and lung cancer. As reported in Issue 31 of this report, the authors reported statistically significant risk estimates for 40 or more "smoke-years" of household exposure during adult- hood and for 22 or more "smoke-years" of exposure during childhood and adolescents. Letters by Peter N. Lee, Maxwell W. Layard, Paul Switzer, and Heather G. Stockwell and several of her co-authors appear in the Journal of the National Cancer Institute 85 (9): 748- 751, 1993. In his letter, Lee states that the Stockwell, et al., paper "adds little to the data on environmental tobacco smoke and lung cancer." He cites several potential sources of bias that could have affected'the reported results. Lee comments on the method of control selection, the high proportion of surrogate respondents among cases, the interviewing process, and the poten- tial for misclassification of smoking habits. Lee also notes that the possibility of dietary confounding was not considered, which he calls "remarkable," as

MttiY 14, 1993 Stockwell and colleagues have elsewhere reported'a "protective effect" of vegetable and carotene consump- tion on lung cancer risk. Lee also criticizes the presen- tation of data in the Stockwell, et al., paper, noting that risk estimates were not given for exposure indices for which no association was daimed. He also presents a table of meta-analysis results of the spousal smoking and lung cancer studies. Layard's letter indudes a discussion of the Candelora, Stockwell, et al., paper on dietary factors that was referenced by Lee. Layard notes that "strong inverse associations" were reported for lung cancer and total vegetable consumption and total carotene intake. Layard notes that the diet analyses did not take into account ETS exposure. He suggests that Stockwell, et al., should explore the possibility of associations between diet and ETS exposure that could lead to confounding. After mentioning another potentialt confounder, a history of nonmalignant lung disease, Layard notes that the "weakness of the overall epidemiologic data" on spousal smoking and lung cancer makes adjustment for potential confounders important. Switzer references an editorial by David Burns, which supported the Stockwell, et al., study, and then states: "[T]he evident inconsistencies pointed out in the Stockwell report should give one pause." In particular, Switzer notes the contrast between theadenocarcinoma data reported in the Stockwell, et al., study (no associa- tion was reported) and the 1992 Fontham, et al., study (statistically significant risk estimates were reported). Switzer writes: "[H]unting expeditions through the data ... can easily produce inconsistent artifacts." Switzer also comments on the large number of risk estimates presented by Stockwell, et al. He proposes that all the risk estimates reported to statistically significant may be related to only one statistically significant estimate, because the risk estimates are "overlapping." Switzer calls for investigators to describe their choices in reporting data, and to publish study protocols and reporting procedures in advance of data collection. Switzer also notes that the Stockwell, et al., paper did not include data on numbers of cases for the individual exposure categories, nor actual risk estimates for workplace and social exposures, calling the latter "a fine example of a publication bias." 11 In their response, Stockwell, et al., indicate that they are analyzing data on dietary factors in persons report- edly exposed'to ETS. They say that the question of a "protective effect" of diet should be considered sepa- rately from the question of ETS exposure. With regard to Layard's comment on prior lung disease as a con- founder, Stockwell, et al., propose that "a shared common exposure to ETS" is "a more likely explana- tion" for prior lung disease in persons with lung cancer. Commenting on Lee's concern about surrogate respondents, Stockwell, et al., suggest that their risk estimates based on surrogates were lower than those based on "self reports"; they suggest that "an even stronger association" would have been reported had fewer surrogates been used. In conclusion, Stockwell, et al., stress that their study had "positive findings," and that "dismissal of all such findings" on ETS exposure is becoming "increasinglydiflicult." CARDIOVASCULAR ISSUES [35] "Carbon Monoxide and Cardiovascular Disease: An Analysis of the Weight of Evidence," J.H. Mennear, Regulatory Toxicology and I'harmacol- ogy 17: 77-84, 1993 [See Appendix A] The author of this review artide discusses the avail- able data on exposure to carbon monoxide and cardio- vascular responses, and the data on carbon monoxide levels in indoor air, including any possible contribution from ETS. He condudes that carbon monoxide could not be responsible for the claimed relationship of ETS exposure and cardiovascular disease. RESPIRATORY DISEASES AND CONDITIONS - CHILDREN [36] "Child Day Care, Smoking by Caregivers, and Lower Respiratory Tract Illness in the First 3 Years of Life," C.J. Holberg, A.L Wright, F.D. Martinez, W.J. Morgan, LM. Taussig, and Group Health Medical Associates, Pediatrics 91(5): 885-892, 1993 [See Appendix A] In this paper, data on child day care attendance and the occurrence of lower respiratory tract illnesses (LRIs)

12 are presented. The authors claim that the presence of three or more unrelated children in the day care setting and smoking by the "caregiver" are "significant inde- pendent risk factors" for LRIs. [37]' "Risk Factors for Developing Wheezing and Asthma in Childhood," W.J. Morgan and F.D. Martinez, Pediatric Clinics of North America 39(6): 1185-1203, 1992 [See Appendix A] The authors of this article discuss current data on potential risk factors for childhood asthma. They suggest that ETS exposure is associated with wheeze in young children and asthma in older children. The authors advocate parental education to reduce exposure to "exogenous risks," including ETS. OTHER CANCER [38] "Risk Factors for Renal Cell Carcinoma: Results of a Population-Based Case-Control Study," N. Kreiger, L.D. Marrett, L Dodds, S. Hilditch, and G.A. Darlington, Cancer Causes and Control 4: 101-110, 1993 [See Appendix A] Canadian researchers report on a case-control study of renal cell carcinoma (cancer of the kidney) in residents of Ontario. A number of potential risk factors were addressed, including active smoking, diet, and body mass. The authors report statistically nonsignificant risk estimates for "passive smoking" in nonsmoking cases, and daim that these data suggest that ETS exposure "appeared to increase risk somewhat." [39] "Parental Smoking and Risk of Childhood Brain Tumors," E.B. Gold, A. Leviton, R. Lopez, F.H. Giles, E.T. Hedley-Whyte, LN. Kolonel, J.L Lyon, G.M. Swanson, N.S. Weiss, D. West, C. Aschenbrener, and D.F. Austin, American Journal of Epidemiology 137(6): 620-628, 1993 [See Appendix A] This study reports on analyses of data collected in a large case-control study of childhood brain tumors. The authors report statistically nonsignificant risk estimates for a number of indices of parental smoking and childhood brain cancer. ETS/IAQ REPORT,,ISSUE 47 OTHER HEALTH ISSUES [40] "Effects of Maternal Smoking Upon Neuropsychological Development in Early Childhood: Importance of Taking Account of Social and Environmental Factors," PA. Baghurst, S.L. Tong, A. Woodward, and A.J. McMichael, Paediatric and Perinatal Epidemiol-ogy 6: 403-415, 1992 [See Appendix A] This Australian study discusses measures of neuropsychological development (e.g., memory, learning, motor skills, verbal performance) in children whose mothers reportedly smoked during and/or after pregnancy, as compared to children of nonsmokers. While scores on the developmental measures were reportedly lower in children of smokers, the difference was not statistically significant after adjustment for a number of social and environmental factors. [41] "Smoking and the Sudden Infant Death Syn- drome," E.A. Mitchell, R.P.K. Ford, A.W. Stewart, B.J. Taylor, D.M.O. Becroft, J.M.D. Thompson, R. Scragg, I.B. Hassall, D.MJ. Barry, E.M. Allen, and A.P. Roberts, Pediatrics 92(5): 893-896, 1993 [See Appendix A] This paper is a further report on the New Zealand Cot Death Study; several reports of data from this study have recently been published. This article, however, focuses extensively on maternal and paternal smoking and the risk of SIDS. The authors report statistically significant associations after controlling for a large number of potential confounding factors. They claim that the criteria for a causal association between parental''smoking and SIDS have been met. [42] "Smoking, Passive Smoking and Smell," P. Hepper, Medical Science Research 20: 265-266, 1992 [See Appendix A] In this study, smokers, nonsmokers, and nonsmokers exposed to ETS were tested for their self-reported ability to perceive an odor. Smokers reportedly re- quired a stronger concentration to identify an odor than did ETS-exposed persons, who, in turn, required a stronger concentration than did nonsmokers.

MAY 14, 1993 ETS EXPOSURE AND MONITORING [,43] "Toxicology of Environmental Tobacco Smoke," M.J. Reasor. In: Toxicology of Combustion Products. L. Manzo and D.F. Weetman (eds.). Pavia, Fondazione Clinica del Lavoro, 71-76, 1992 [See Appendix A] This brief review discusses the chemistry of ETS and the use of biological markers to estimate exposure. The author also calls for research using animal models and in vitro tests to address the "controversy" surrounding the toxicology of ETS. INDOOR AIR QUALITY [44] "Priority Among Air Pollution Factors For Preventing Chronic Obstructive Pulmonary Disease in Shanghai," X. Tao, C.J. Hong, S. Yu, B. Chen, H. Zhu, and M. Yang, The Science of the Total Environment 127: 57-67, 1992 [See Appendix A] In this study, Chinese researchers report on the comparison of sulfur dioxide levels, particulate levels, and indoor coal use with data on chronic obstructive pulmonary disease and lung function in residents of Shanghai. They condude that use of coal indoors was the most important of the factors studied. [45] "Emissions of Volatile Organic Compounds from New Carpets Measured in a Large-Scale Environmental Chamber," A.T. Hodgson, J.D. Wooley, and J.M. Daisey, Journal of tbe A:r and Waste Management Assoeiation 43: 316-324, 1993 [See Appendix A] In this study, VOC emissions from four new carpets were studied in an environmental chamber. Formalde- hyde and 4-phenylcydohexene (source of the "new carpet" odor) were identified, at levels which the researchers characterized as "low." The authors call for additional research on the potential of health effects from exposure to these VOCs. 13 SMOKING POLICIES AND RELATED ISSUES [46] "Clean Indoor Air Legislation, Taxation, and Smoking Behaviour in the United States: An Ecological Analysis," S.L. Emont, W.S. Choi, T.E. Novotny, and GA. Giovino, Tobacco Control2: 13-17, 1992 [See Appendix A] The authors of this study, two of whom are with the U.S. Office on Smoking and Health, compare state indoor air laws (smoking regulations) and data on cigarette consumption, smoking prevalence, and proportion of "quitters." They conclude that more restrictive regulations are associated with lower smok- ing prevalence and a higher proportion of quitters. They suggest that indoor air regulations could be used to "reduce tobacco consumption globally." IN EUROPE& AROUND THE WORLD REGULATORY AND LEGISLATIVE MATTERS AUSTRALIA [47] Health Authority Considers Restaurant Smok ing Ban The Eastern Metropolitan Regional Health Authority has reportedly recommended that the Health Commis- sion impose a smoking ban in all South Australian restaurants, fast-food chains, cafeterias and hotels. The Health Minister apparently favors an approach to the issue that emphasizes education rather than legislation, and the Hotel and Hospitality Industry Association strongly supports self-regulation. The Government, however, has evidently warned the public that smoking may be outlawed in food outlets unless businesses provide smoke-free zones. See Advertiser, May 4, 1993. [48] Cab Drivers Respond to Taxi Smoking Ban Adelaide cab drivers are reportedly unhappy that the industry was not consulted before a ban on smoking in

14 South Australia's taxis and hired cars was adopted. However, according to the SA Taxi Association president, drivers and the industry generally favor a ban because of the "terrible risk" of health-related damages claims. The ban will apparently go into effect before the end of the year. See Advertiser, April 30, 1993. AUSTRIA [49] Shop Owners Protest Government Plans to Restrict Smoking Some 10,000 news agents and tobacconists reportedly staged a one-day strike, dosing their shops to protest Health Minister Michael Ausserwinkler's plans to impose smoking restrictions in public places. See issue 42 of this Report, March 5, 1993. According to a press report, one thousand demonstrators marched through the streets of Vienna, claiming that the measures could result in the loss of 30,000 jobs. See The European, Apri129, 1993. IRELAND [50] Dublin Corporation Considers Workplace Smoking Policy According to a press report, Dublin Corporation is assessing its workplace smoking policy in light of the settlement reached in the Veronica Bland case, wherein an employee received $21,500 for injuries allegedly caused by ETS exposure. See issue 40 of this Report, February 5, 1993. According to a spokeswoman, no similar claims have been filed'against the corporation, which is currently conducting a staff survey to ascertain attitudes toward workplace smoking. A survey of this nature was undertaken in 1991, and, at that time, 93 percent of those surveyed favored restrictions on smoking in the workplace. See The Irish Times, April 16, 1993. ETSIIAQ REPORT, ISSUE 47 ETS/IAQ LITIGATION NOT INVOLVING CIGARETTE MANUFACTURERS AUSTRALIA [51] Mansf:eld v. The Herald d" Weekly Times Ltd (Victoria County Court, Melbourne) (filed November 19, 1992) On Apri129, 1993, the defendant's application to set aside the plaintiff's interlocutory judgment in default was heard and granted in this case, in which an em- ployee claims workplace exposure to ETS caused his throat cancer. See issue 37 of this Report, December 18, 1992. The Master instructed the parties to agree upon a timetable for the filing of a defense. LEGAL ISSUES AND DEVELOPMENTS SINGAPORE [52] Ministry of Health Conducts Workplace Smoking Seminar According to a press report, the Singapore Ministry of Health conducted a seminar for senior management representatives of private companies about workplace smoking. An attorney speaking at the seminar report- edly advised participants that employers can legally impose rules against smoking in the workplace and cannot be sued by smokers if they do so. He also said employers cannot be sued by nonsmokers if no smoking restrictions are adopted. See The Straits Times, May 7, 1993. OTHER DEVELOPMENTS AUSTRALIA [53] Author Addresses Scare Tactics Intended to Modify Behavior According to a press report, retired physicist and senior federal bureaucrat Dr. John Farrands decided to tackle the issue of the use and abuse of science to create fear. In his book entitled "Don't Panic, PANIC!"

MAY 14; 1993 Farrands exposes what he considers to be improper attempts to modify behavior by "thought police" who base their efforts on fragmentary information. He apparently explains that such manipulation covers a whole range of issues, including smoking, diet and cholesterol. See The Australian, May 3, 1993. [54] Doctors Disagree with Studies on Asthma and Pollution According to a press report, doctors insist that colds and flu, housedust mites, pollens, molds and ETS are the primary triggers for asthmatic attacks. While studies overseas link ambient air pollutants to asthma, Australian doctors say the air quality in Australian cities has only a minor effect on the incidence and severity of asthmatic attacks. See Sydney Morning Herald, May 5, 1993. [55] Survey Reveals 77 Percent of Top Companies Have Smoking Policies The results of a national survey on workplace smok- ing policies were apparently recently published in 1992 in the booklet, "Workplace Policies and Programmes for Tobacco, Alcohol and other Drugs in Australia." The survey reportedly indicated that 77 percent of Australia's top 455 companies have introduced work- place smoking policies. Of the companies surveyed, some 46 percent impose a total smoking ban, 31 percent limit smoking to designated areas, and 23 percent had no policy. See Financial Reuiew, Apri129, 1993: CANADA [56] Canadian Carpet Industry Adopts Voluntary Testing Program According to a news report, Canadian carpet manu- facturers are adopting a voluntary carpet testing program already used in the United States. The program, soon to be implemented, calls for placement of a green tag to mark carpets that have been tested by an independent laboratory and found to emit less than 0.6 milligrams per square meter of volatile organic compounds per hour. However, Canadian government and consumer officials, consumer groups and those in the industry have been reported to say there have been very few complaints in Canada about carpets and 15 negative health effects. According to a spokesman in Health and Welfare Canada's environmental health directorate, no dear link between carpet and serious health problems has yet been established. See The Ottawa Citizrn, May 1, 1993. HONG KONG [57] Survey Reveals Support for Smoking Bans According to a survey conducted by Hong Kong University for the Hong Kong Council on Smoking and Health (COSH), the majority of those surveyed favored bans on smoking in child care facilities, schools, workplaces and public places. Seventy-nine percent of those surveyed reportedly wanted nonsmok ing areas to be designated in restaurants. Survey results have apparently been forwarded to the Health and Welfare branch, and the director of COSH hopes antismoking legislation will be introduced sometime this year. Some 1,222 people over the age of 18 were reportedly interviewed for the survey; approximately 12 percent were smokers. See South China Morning Post, Apri128, 1993. SINGAPORE [58] Survey Finds Sick Buildings According to a news report, SGS Singapore found five percent of 30 buildings tested were "sick" An organization dealing in inspection and control services, SGS Singapore reportedly conducted IAQtesting in 30 buildings, induding offices, a shopping complex and two private homes. See The Straits Tinu!s~ April 24, 1993. UNITED KINGDOM [59] BAT Publishes Brochure on "Social Engineering" BAT has published a brochure entitled "Smoking: 'Fear of living' and Social Engineering in the Late Twentieth Century." The brochure focuses on what is perceived as the American preoccupation with risks and' discusses the ways in which U.S: laws and litiga- tion appear to be taking the enjoyment out of life. BAT concludes, "When the air outside cannot be breathed without choking in many cities around the world, when typhoid and cholera epidemics still rage in

16 places without adequate basic sanitation, it is sheer madness to become preoccupied with follies such as 'scent rape' and the hypothetical risks presented by a glass of wine at dinner or a whiff of someone's cigarette." WORLD HEALTH ORGANIZATION (WHO) [60] WHO Meets In Geneva for 46th World Health Assembly A debate on tobacco issues took place during the 46th World Health Assembly held in Geneva on May 3-14, 1993. Delegates from several countries reportedly observed that legislation, awareness campaigns and research studies were ongoing as part of general anti- tobacco activities. Forty-two countries apparently tabled a resolution calling on the WHO director- general to approach the United Nations secretary- general for purposes of urging him to ban the use of tobacco in buildings owned, operated or controlled by all UN organizations and specialized agencies. The resolution calls for progressive implementation of this ban within two years. MEDIA COVERAGE CANADA [61 ]"Tobacoo Smoking in Aircraft - A Fog of Legal Rhetoric?," R.I.R. Abryratne, Air cr Space Law, No. 2 1993 The author of this artide traces the efforts that have been taken in recent years by segments of the interna- tional aviation community to recognize the alleged adverse health and safety effects of smoking on air- planes. An extensive quote from an artide by W. Allan Crawford about a 1988 study is set forth, including its condusion that available scientific evidence does not support a ban on smoking in commercial aircraft. The article acknowledges that "an aircraft in flight is a pressurized, airborne, air-conditioned, densely popu- lated tourist and business facility at a high altitude with a relative humidity similar to that of Antarctica. Inside the aircraft, humans release on occasion hostile viruses and bacteria, shed dead skin particles, fungal spores ETS/IAQ REPORT, ISSUE 47 and emit body odours." Yet, the author concludes that the "only known pollutant" in the aircraft is ETS. Several cases from the United States involving nonsmokers' daims against the airlines are discussed, and the author suggests that the act of exhalation of tobacco smoke in an endosed area could be classified as a tort and that regulators should take this into consideration when addressing the alleged problem of ETS in aircraft.

MAY 14„ 1993 APPEN!DIX A LUNG CANCER [32] "The Etiology of Lung Cancer," D.G. Davila and D.E. Williams, Mayo Clinic Proceedings 68: 170-182, 1993 "A more complete understanding of the causes of lung cancer has long been an elusive goal of clinicians and basic scientists.... [I]n contrast to many other malignant diseases, most cases of lung cancer can be prevented though avoidance of incriminated environ- mental factors." "This review of the causes of lung cancer is the first contribution in a series of artides that will address the various dinical aspects of this disease. Herein we review some of the chemical and physical exposures, dietary factors, and lung,diseases that have been associated with lung cancer. In addition, we discuss some of the recent studies that suggest a heritable predisposition to the disease and describe some of the cellular and molecular defects in lung tumors that are prominent factors in two proposed models of lung carcinogenesis. Finally, we comment on future directions of research in this area." "Chemicals in tobacco smoke are the best-known lung carcinogens; this association has been noted for more than 50 years." "Although the incidence of lung cancer among those who passively inhale environmental tobacco smoke is clearly increased, the exact level of increased risk is unknown and controversial...`Passive smokers' or nonsmokers who breathe environmental tobacco smoke are thought to inhale qualitatively similar tobacco smoke contents but quantitatively lesser amounts." "Assigning a definitive level of increased risks for lung cancer from passive exposure to tobacco smoke has been problematic because no truly unexposed control group exists for comparison. Hence, differences in risk between those known to be exposed to environmental tobacco smoke and the so-called control groups are likely to be small and difficult to demonstrate." "Overall, odds ratios for lung cancer among passive smokers have been estimated to be 1.24 (95% confi- dence interval, 1.04 to 1.5) in case-control studies and 1.44 (95% confidence interval, 1.2 to 1.72) in prospec- tive studies." A-1 "Despite the limitations of some of these studies, the 1986 Surgeon General's report, the National Academy of Sciences, and the International Agency for Research on Cancer all formally recognize the increased risk of lung cancer from passive exposure to smoke...The most recent review from the Environmental Protection Agency of the health effects of passive smoking as it pertains to lung cancer is in preliminary draft form and will likely influence policies about smoking in the workplace." "The causes of lung cancer will continue to be studied at the epidemiologic level. Population-based prospec- tive studies will focus on determining potential dose- response relationships between lung cancer and environmental tobacco smoke with use of better measures of exposure." [331 "Implications for Disease Misclassification in Epidemiological Studies of Lung Cancer Risk for Nonsmokers Exposed to Environmental To- bacco Smoke," A.W. Katunstein, Environment International 19: 211-212, 1993 "The U.S. Environmental Protection Agency (EPA) appears to have diminished or dismissed the potentially significant role of disease misclassification in its review of lung cancer risk in nonsmokers reportedly exposed to environmental tobacco smoke (ETS)...EPA made no attempt to adjust for potential disease misclassification, which is more likely to result in overestimation than underestimation of relative risk." "Disease misclassification arises when 'lung cancer cases' are not primary lung carcinomas but are second- ary cancers that have metastasized to the lung from primary tumors originating in other body tissues. Definitive diagnosis of primary lung cancer requires histological or cytological examination of lung tissue." "The potential effect of disease misdassification can be illustrated in the study of Hirayma (1984) in Japan, which was among the earliest of the epidemiological assessments said to find lung cancer risk in nonsmokers married to smokers." "EPA reported a crude relative risk of 1.38 (90% C.I. 1.03-1.87). There is potential disease misclassification, however, for all 2001ung cancer cases, with more than four and one-half times as many cases among those exposed to ETS than among those not exposed."

A-2 "If as few as four of the 163 lung cancer cases exposed to ETS were disease misclassified - i.e., were not primary lung carcinomas - the relative risk would be a statistically nonsignificant 1'.34 (C.I. 0.99-1.71)." "Of the 31 epidemiological studies in the data base of the EPA Review Draft, all lung cancer cases of 12 studies were reported to have been histologically or cytologically confirmed. In 14 studies, from 2% to 100% of the lung cancer cases had not been defini- tively confirmed, while in 5 studies, the method and extent of verification were not reported." "For all case-control studies where the extent of diagnosis confirmation was established, EPA data show 302 lung cancer cases not definitively confirmed." "The EPA Review Draft shows 64% of the cases were classified as exposed to ETS, so that there may be nearly twice the likelihood' of disease misclassification among 'cases' classified as exposed to ETS as among those not exposed. However, any assumptions about the distribution of disease misdassifications in specific studies or in the overall data base would be entirely speculative and insupportable." "The failure to give appropriate consideration in the EPA Review Draft to the significant potential for disease misdassification reduces confidence in risk estimates derived from the data and raises serious ques- tions about public health policies based on such studies." CARDIOVASCULAR ISSUES [35] "Carbon Monoxide and Cardiovascular Disease: An Analysis of the Weight of Evidence," J.H. Mennear, Regulatory Taxicabgy and Pharmacol- ogy 17: 77-84, 1993 "The mechanism(s) [through] which either active or passive smoking might increase risk of cardiovascular disease have yet to be unequivocally defined. A promi- nent and frequently mentioned cause or contributor is the production of myocardial ischemia through exposure to ETS-associated carbon monoxide. The purpose of this review is to weigh the evidence relative to the hypothesis that ETS-related exposures to carbon monoxide (CO) can contribute to either the initiation or exacerbation of ischemic cardiovascular disease in humans. The results of this review show that there is little clinical or experimental evidence that is relevant ETS/IAQ REPORT, ISSUE 47 to the issue and that that which is available does not support a role for ETS-associated carbon monoxide in the causation or exacerbation of ischemic heart disease in non/never-smoking humans." "Carbon monoxide, produced during the incomplete combustion of all organic materials, is the most extensively studied and best understood component of either mainstream or sidestream cigarette smoke. This gas avidly competes with oxygen for binding to hemoglobin (Hb). The combination of CO with HB results in the formation of carboxyhemoglobin (COHB) and compromises the transport of oxygen to the tissues of the body." "Overall, the results of studies in humans afford some evidence that exposure to extremely high concentra- tions of CO may elevate risk of ischemic heart disease and decrease the exercise tolerance of people with coronary artery disease. Such effects are consistent with the production of systemic anoxia and impaired myocardial oxygenation. However, it remains to be established whether ETS can contribute sufficient environmental CO to impact on the cardiovascular status of either healthy or compromised humans." "It has been frequently and correctly noted that sidestream tobacco smoke contains a higher concentra- tion of CO than does mainstream smoke...American cigarettes are recognized to deliver approximately 15 mg/cigarette of CO via mainstream smoke and 50 mg/ cigarette via sidestream smoke." "This relatively high concentration in sidestream smoke has led many to conclude that ETS is a major contributor to environmental CO concentrations. Such a conclusion is not supported by the results generated in field studies during which the air in residences, work places, and public places has been analyzed under both smoking and nonsmoking conditions." "On the basis of the available data obtained from fleld studies, it is clear that ETS contributes CO to the environment. However, the increment of environmen- tal CO attributable to tobacco smoking is exceedingly small. Further, this small increase is easily masked by normal day-to-day variations in ambient concentra- tions which are attributable to the presence of other CO sources such as automobiles and the combustion of heating and cooking fuels."

MAY 14, 1993 "While conducting this analysis no attempt was made to directly address the issue of whether or not exposure to ETS per se causes or exacerbates cardiovascular disease. The results of this review have established, however, that if the purported impact of ETS on cardiovascular disease is real, it can be neither ex- plained nor mediated thorough ETS-associated increases in ambient concentrations of carbon monox- ide. There is scant evidence to support a role for carbon monoxide in the causation of ischemic heart disease. Further, the results of field studies of air quality in nonsmoking and smoking homes, offices, and public places demonstrate that ETS contributes only minor and toxicologically insignificant increments in ambient carbon monoxide concentrations. These increments are variable and easily masked by other commonly encountered carbon monoxide sources such as internal combustion engines and the burning of cooking and heating fuels." RESPIRATORY DISEASES AND CONDITIONS - CHILDREN' [36] "Child Day Care, Smoking by Caregivers, and Lower Respiratory Tract Illness in the First 3 Years of Life," CJ. Holberg, A.L. Wright, F.D. Martinez, W.J. Morgan, LM. Taussig, and Group Health Medical Associates, Pediatrics 91(5): 885-892, 1993 "Day-care attendance has been associated with an increased risk of hospitalization for lower respiratory tract illnesses (LRIs): This study examines, in a health maintenance organization population of children, the associations between child day care and the occurrence of LRIs in the first 3 years of life. Smoking by caregivers and a possible protective effect of longer day- care enrollment in relation to LRIs are also addressed." "Information on day-care arrangements was elicited from 1006 parents of infants for five age intervals in the first 3 years of life: birth through 3 months, 4 to 6 months, 6 to 12 months, 1 to 2 years, and 2 to 3 years. Data on LRIs in the first 3 years of life were recorded by pediatricians at the time of the acute illnesses." "This study has shown that the risk of LRI increases up to twofold or more for children, between 4 months and 3 years of age, who are in child care situations A-3 involving the presence of three or more unrelated children. The association is independent of other implicated risk factors, including type of and time spent in the child care setting, maternal education, number of others sharing the child's bedroom, having other siblings, parent history of respiratory trouble, maternal smoking, smoking in the child care setting, gender, and ethnicity. Beyond the threshold of three or more unrelated children in the child care setting, there is no evidence in this population to suggest that increasing numbers are associated with increased LRI risk. Prior to 4 months of age, an increased risk associated with the number of others present is not apparent. At this younger age, the risk is associated simply with being in any child care setting other than at home." "After controlling for other risk factors, the presence of siblings was associated with risks of LRI of similar magnitude to those of exposure to unrelated children in the child care setting, but only in the first 6 months of life. This would imply that although the nature of the risk associated with unrelated children or other siblings is similar, the source of the contacts is associ- ated with a different risk profile. Thus, our results suggest that while there is a constant ongoing risk associated with exposure to unrelated children, in the first 3 years of life, the LRI risk associated with having other siblings is present only during the first year, and then it decreases, possibly becoming protective in the second and third years of life. This suggests there is a more limited exposure to infection associated with the presence of the same group of children, since the total number of contacts is reduced." "After controlling for other risk factors, induding maternal smoking, the present study has further demonstrated an increased risk for wheezing LRIs of up to threefold or more in the third year of life in those infants who are in a child' care setting with a smoking caregiver. To our knowledge, this is the first demon- stration of a passive smoking effect in children attribut- able to sources outside of the home environment. The reason why this effect would be seen in the third year of life is not apparently due to an increase in the amount of time spent in the care setting, as we had initially thought. However, the majority of infants in their third year of life in another home setting with a caregiver who smoked were also with a caregiver who smoked' in their second year of life. This suggest that

A-4 prolonged exposure to environmental tobacco smoke may increase the risk of wheezing LRIs." "Over the first 3 years of life approximately one fifth of infants of nonsmoking mothers were in a care setting with a smoking caregiver. Also, we find that infants of mothers who smoke are more likely to be placed in a child care setting with a smoking caregiver compared with infants of nonsmoking mothers. There were relatively few heavily smoking mothers who placed their child in a care setting where there was no smoking." "Given the continued widespread utilization of child day-care, the findings of this study suggest that the risk of LRIs would be reduced in care settings involving fewer than three unrelated children. This could be particularly relevant in the first 6 months of life, when the incidence of LRI is highest. In addition, child'day- care in the absence of environmental tobacco smoke would decrease the risk of LRIs." [371 "Risk Factors for Developing Wheezing and Asthma in Childhood," W.J. Morgan and F.D. Martinez, Pediatric Clinies of North Ameriea 39(6): 1185-1203, 1992 "Wheezing respiratory illness and asthma are respon- sible for a significant proportion of both acute and- chronic illness in childhood. Affecting approximately 5% to 10% of children, asthma is of growing concern because of an apparent increase in mortality and morbidity. The risk factors associated with the develop- ment of wheezing illness and asthma have therefore been the focus of much investigation in the last two decades." "This article first reviews risk factors for wheezing in infancy and the toddler years. The possibility that early viral-related wheezing illness predisposes to later asthma and chronic lung dysfunction is then discussed. With this background, risk factors for the development of persistent asthma in later childhood are explored, with particular attention to the role of allergy in the pathogen- esis of chronic airway inflammation and asthma." "Both exogenous factors deriving from the child's life experience and endogenous (congenital) factors may increase the risk of wheezing in infancy." "Parental, particularly maternal, cigarette smoking has been clearly associated with an increased risk of wheezing, respiratory symptoms, lower respiratory tract ETS/IAQ REPORT, ISSUE 47 illness, and hospitalization in exposed infants.... The effect of maternal smoking has been assumed to be due to passive inhalation of sidestream tobacco smoke by the infant. This might then result in airway inflamma- tion and other alterations favoring both viral infection and the development of dinical wheezing illness or pneumonia. Recently, preliminary results from several studies have suggested that this relationship also may be due to alteration of the developing lung by maternal smoking, leading to a greater risk for wheeze with infection. Maternal smoking during pregnancy results in fetal stress secondary to both intrauterine hypoxia and nicotine exposure. Whereas the growth retardation associated with maternal smoking during pregnancy is well known, lung-specific effects may occur as well, induding a reduction in lung elastin content." "[A] significant proportion of children (25%) wheeze before 3 years of age, but only a minority go on to develop asthma. This remission in wheezing illness may occur in some children because of lung growth and development. In other children, however, the presence of allergy and other factors leads to the development of asthma independent of prior wheezing lower respiratory tract illness history. Risk factors for the development of asthma in later childhood' are discussed here." "[T]here is convincing evidence that an allergic inflammatory reaction occurring in the airways is almost certainly necessary for the development of asthma in children more than 5 years of age. Moreover, the severity of asthmatic symptoms may be directly related to the degree of sensitization to aeroallergens. A better understanding of the mechanisms bywhich~ allergy causes asthma may help to identifypredisposing factors for asthma." "Several studies have suggested that children exposed to environmental tobacco smoke in their homes may be at increased risk of developing asthma....Not all studies have been able to confirm these findings, but the number of cigarettes smoked and the educational level of the mother were not always adequately con- trolled in the negative studies. It is thus quite likely that exposure to cigarette smoke may cause asthma in susceptible children." "The mechanisms by which environmental tobacco smoke may cause asthma are not well understood. Recent studies in Italian schoolchildren showed k

MAY 14', 1993 increased sensitization to aeroallergens, increased IgE levels, and increased prevalence of eosinophilia in children of smoking parents. Environmental tobacco smoke also may enhance bronchial responsiveness, and this effect is apparently independent of that of passive smoking on allergic sensitization " "Wheezing lower respiratory tract illness in infancy and asthma share the clinical findings of wheezing and respiratory distress. Although the link between wheez- ing lower respiratory tract illness in infartcy and the subsequent development of asthma is a limited one, both conditions do share some common risk factors, including exposure to environmental tobacco smoke, difficult living conditions (low socio-economic dass, crowding, allergen exposure), and increased risk in males....Altliough the endogenous risks for these two outcomes may be fixed, it is clear that caregivers inay help to reduce or eliminate the exogenous risks listed earlier by parental education and improvement of the living conditions of young children." OTHER CANCER [38] "Risk Factors for Renal Cell Carcinoma: Results of a Population-Based Case-Control Study," N. Kreiger, LD. Marrett, L Dodds, S. Hilditch, and G.A. Darlington, Cancer Causes and Control 4: 101-110, 1993 "It has only been in the last few years that renal cell carcinoma has become the focus of epidemiologic research, and many questions about risk faaors remain. The study reported here was designed to elucidate the importance of a number of potential risk factors, including active and passive cigarette smoking, body mass, diet, use of analgesic and diuretic medications, and hormonal effects." "This population-based case-control study encom- passed the province of Ontario, and induded all newly diagnosed, histologically confirmed, cases of renal cell carcinoma diagnosed in 1986 or 1987, who were aged 25-69 years and resided in Ontario at the time of diagno- sis. Cases were ascertained through review of pathology reports received by the Ontario Cancer Registry." "Passive smoking was not confined to cigarette smoke, but induded exposure to cigar and pipe smoke as well. Subjects reported their usual passive exposure A-5 in three categories (<3, 3-8, or <8 hours per day) combining home and workplace exposures." "The risk associated with passive smoking,was assessed among never-smokers only. In males, no statistically significant effect was observed; in females, inclusion of passive smoking resulted in a statistically significant improvement in the model. The highest exposure level'i (more than eight hours' passive smoking per day) was associated with a risk of 1.6 (CI = 0.5-4.7) for males, and 1.7 (CI = 0.8-3.4) for females." "Our data show that for female smokers, in contrast to male smokers, the reported inhalation of tobacco smoke is an important variable. Consistent with this sex difference is the difference in the effects of passive smoking: in females, passive smoking significantly increased risk; while in males, there is no significant effea of passive smoking. This finding is in conwr- dance with a report of passive smoking and cancer risk in adults showing greater relative risk among groups with lower overall cancer risk. It is possible that the effects of inhaling and of passive smoking may be more difficult to detect in men, given the smaller numbers of male nonsmokers with high levels of passive smoke exposure. Women who smoke do so at lesser amounts than men, and may inhale smoke differently, leading to a greater relative contribution to total exposure of passive smoke or to a greater potential for passive - smoke to have an effect on risk." "In summary, we have confirmed the association between active cigarette smoking and increased risk of renal cell carcinoma among both males and females and have provided data suggesting passive cigarette smoking to be of importance. Our data indicate that 41 percent of renal cell carcinoma in males, and 28 percent in females, may be attributed to ever having smoked cigarettes. In addition, while dietary intake, particularly of fats, does not account for a large per- centage of renal cell carcinoma in Ontario, possibly 17 percent in males and 26 percent in females may be attributed to having a high [body mass index] at some time in life. Given these attributable risks, there is consid- erable potential for reduction of the incidence of renal cell carcinoma through modification of these factors."

A-6 [39] "Parental Smoking and Risk of Childhood Brain Tumors," E.B. Gold, A. Leviton, R. Lopez, F:H. Giles, E.T. Hedley-Whyte, LN. Kolonel, J.L. Lyon, G.M. Swanson, N.S. Weiss, D. West, C. Aschenbrener, and D.F. Austin, American Journal ofEpidemiology 137(6): 620-628,1993 "We used data obtained in one of the largest, popula- tion-based case-control studies of childhood brain tumors, to undertake the present set of analyses, to assess the role of parental smoking in the risk of the most frequently occurring solid tumors in children. The size of the study and the level of detail of parental smoking information obtained permitted an in-depth investigation of this important question with a high level of statistical power." "Cases were identified from eight population-based Surveillance, Epidemiology, and End Results (SEER) program tumor registries, representing a combined annual catchment population of 4.72 million children." "Information on demographic characteristics, occupa- tional history, personal and family medical histories, and habits induding smoking was obtained from each parent for both cases and controls in a structured interview in the home. Interviews were completed for 361 children with brain tumors and 1,083 control children." "No significant differences were found between cases and controls in maternal or paternal smoking at any time or specifically during the year the index child was born (induding both the prenatal and early postnatal periods) or 2 years before the index child was born, which also induded the preconception period. These analyses were stratified by parental educational level to control for its potential confounding effect, which was found to be nil. The potential confounding effects of alcohol, coffee, and tea consumption were also exam- ined and not found to affect in any substantial way the lack of observed effect of parental smoking on risk of childhood brain tumors. The estimated relative risk associated with smoking more than one pack per day also was not significantly greater than that for smoking less than one pack per day." "Maternal smoking, or exposure to cigarette smoke during pregnancy, has been associated with brain tumors in children in one study, but not in others. The negative studies are similar to the present study in that they: 1) interviewed and incorporated information ETS/IAQ REPORT, ISSUE 47 about fathers, 2) identified controls randomly from the population, and 3) individually matched controls to cases. The positive study is the largest study prior to the present one but interviewed only mothers of cases and of friend and neighborhood controls." "However, one possible explanation for the discrepant findings is when the data were collected. The one study that found an association between childhood brain tumors and maternal exposure to sidestneam smoke was conducted years before the studies that did not find this association. Our data were collected during the same time that the null studies were conducted." "If the time period that the data were collected accounts for the observed difference, then at least two inferences are possible. One is that with the recent decline in the prevalence of maternal smoking has come a loss of statistical power. Another inference is that the number of pregnant women who smoke has not really dedined, but only the truthful acknowledgement of cigarette smoking has dedined." "[O]dds ratios for all brain tumors, as well as for astrocytoma and medulloblastoma, tended to be dose to unity, and thus provide no evidence for any in- creased risk associated with maternal or paternal smoking prior to or during pregnancy or with passive exposure to parental smoking postnatally. While these findings obviously do not outweigh the many other significant health hazards to parent and child associated with parental smoking, the consistency of these findings in one of the largest studies of childhood brain tumors provides strong evidence that parental precon- ception or pre- or postnatal smoking does not affect the risk of brain tumors in the offspring." OTHER HEALTH ISSUES [40] "Effects of Maternal Smoking Upon Neuropsychological Development in Early Childhood: Importance of Taking Account of Social and Environmental Factors," PA. Baghurst, S.L. Tong, A. Woodward, and A.J. McMichael, Paediatric and Perinatal Epidcmiol- ogy 6: 403-415, 1992 "Since the possible long-term effects of maternal smoking on childhood neuropsychological develop- ment are of great theoretical and practical importance,

MAY 14', 1993 the question has emerged of whether the reported lower neuropsychological funaioning of children can be attributed to exposure to maternal smoking or to other coexistent aspects of the child's social and environmental circumstances." "The results reported in this paper come from a follow-up study of 548 4-year-old children whose mothers were recruited during pregnancy..._The analyses focus on the associations of the neuropsychological outcome in childhood with maternal smoking, and a number of key social and environmental factors. Evidence is provided that the decrements in children's neuropsychological function- ing associated with antenatal or postnatal exposure to maternal smoking are not as large as those attributable to the child's social and environmental factors, and that appropriate adjustment for these factors may explain the mild association between exposure to maternal smoking and neuropsychological development in children." "The analyses of children's scores on the...scales of children's abilities with postnatal exposure to maternal smoking showed that the children of smokers per- formed at 2.4 to 4.196 lower level in most of the testing sessions by comparison with those of non- smokers.... The decrements in...scores in the children of smokers were statistically significant. The children with postnatal exposure to maternal smoking also had lower scores for...verbal, perceptual-performance and motor subscales." "However, no significant differences were found between the scores of children with antenatal exposure to maternal smoking and those of children with no antenatal exposure." "These results reveal a statistically significant inverse association between maternal smoking and neuropsychological development which becomes quite insignificant when other putative determinants of development are taken into account. Interpretation of these findings is therefore difficult, and must take into account both the reliability of the exposure measures, and the more general problems of selection bias, and `over-adjustment'." "[S]ocio-economic status, the home environment provided by the parents and maternal IQ all make significant inroads into the crude association of poor development with maternal smoking, and corroborates A-7 the results of earlier studies. While it may still be argued that smoking reduces a woman's IQ and renders her less able to provide a highly stimulatory home environment for her children, there is little published evidence on which to base such speculation." "We conclude that there is, at present, no strong evidence that maternal smoking exerts an independent effect upon neuropsychological development in early childhood. A major reason for the inconsistent results observed in this area may be confounding due to social and environmental factors. If passive smoking does have an effect on the development of children's abilities, it is likely to be difficult to detect in the presence of wide variations in these factors. In order to gain a dearer understanding of this problem, more precise measures of exposure to environmental tobacoo smoke, both in uttro and posaiatally; may also be required." [41] "Smoking and the Sudden Infant Death Syn- drome," E.A. Mitchell, R.P.K. Ford, A.W. Stewart, B.J. Taylor, D.M.O. Becroft. J.M.D. Thompson, R. Scragg, I.B. Hassall, D.MJ. Barry, E.M. Allen, and A.P. Roberts, Pediatrics 92(5): 893-896, 1993 "One way to assess the importance of passive smoking is to examine the effect of smoking by the father and other - household members on the risk of SIDS. This paper reports the effects of maternal smoking during pregnancy and the effecrs of smoking by the mother, father, and other household members after the infant's birth." 'Infants of mothers who smoked during pregnancy had a fourfold' greater risk of SIDS than infants of mothers who did not smoke. Infants of mothers who stopped'smoking during pregnancy had a lower risk of SIDS, but this was not statistically significant. Infants of mothers who smoked in the previous 2 weeks had an increased risk of SIDS compared with infants of nonsmokers. Furthermore, the risk increased with increasing levels of maternal smoking. Similarly, infants of fathers who smoked in the previous 2 weeks had an increased risk of SIDS, but a dose effect was not evident. The number of smokers in the house (parents and other household member) also increased the risk of SIDs, as did the presence of smoking by other house- hold member, excluding the parents."

A-8 "The relationship of maternal smoking status with other variables was examined in the control group. As expected, maternal smokers as a group were signifi- cantly more likely to be of.lower socioeconomic status, Maori, of lower educational level, unmarried, younger at first pregnancy, younger at the birth of the infant, late attenders at antenatal classes, and nonattenders at antenatal education classes; to have infants of lower birth weight; not to breast-feed; and to share the bed with their infant. Maternal smokers did not differ from nonsmokers for infant's sex, number of previous pregnancies, gestation, admission to neonatal unit, season, and infant's sleeping position." "After controlling for region, time of day, season, marital status of mother, socio-economic status, ethnic group of infant, mother's age at birth of infant, infant's sex, birth weight, age of infant, breast-feeding, sleep position, and infant sharing bed with another person, we found that maternal smoking was still significantly associated with an increased risk of SIDS (OR = 1.65; 95% CI = 1.20, 2.28), as was smoking by the father (OR = 1.37; 95% CI = 1.02, 1.84)." "The number of smokers in the household was associated with a significantly increased risk of SIDS after control for potential confounders (1 household smoker OR = 1.12, 95% CI = 0.77, 1.63; 2 smokers OR = 1.75, 95% CI = 1.23, 2.48; 3+ smokers OR = 2.07, 95% CI = 1.26, 3.41). The presence of smoking by others in the house (exduding parents) was not a significant risk factor after smoking by the mother and father and other potential confounders were controlled." "The effect of smoking by the father increased the risk of SIDS if the mother smoked, but not if she did not smoke." "Maternal smoking increased the risk to the baby substantially, but lack of breastfeeding had a further and independent effect." "The effect of smoking by the father has not been examined in detail previously. Although one study has shown smoking by the father to be a risk factor for SIDS, that study did not control for maternal smoking. This is essential as we have shown that maternal and paternal smoking behaviors are related. We found that the increased risk of SIDS from paternal smoking persisted after controlling for maternal smoking and their potential confounders. We were unable to ETS/IAQ REPORT, ISSUE 47 demonstrate a dose-response curve for paternal smok- ing. This may have occurred because much of the father's smoking is done away from the house. But when the combined effects of parental smoking are considered, it appears that the father's smoking increases the risk of SIDS when the mother smokes, but not if she does not smoke. We did not expect the lack of effect of father's smoking when the mother is a nonsmoker, but it may be that a nonsmoking mother is more likely to insist that a smoking father smoke away from the infant." "Finally, we address the central question: 'Is smoking causally related to SIDS?' Criteria for causation in an observational study such as this are as follows:" "• Temporal relationship where the putative risk factor precedes the event. This criterion is obviously fulfilled, particularly since information on smoking during pregnancy was collected in obstetric records prior to the death." "• Consistency of the findings. Maternal smoking has been identified as a risk factor for SIDS in many studies." "• Strength of association. The stronger the associa- tion, the more likely the risk factor is causally related. In this study different measures of maternal smoking have ORs greater than 4, which is moderately strong." "• Biological gradient. In this study a biological gradient was seen for the amount the mother smoked, the number of smokers in the household, and possibly,, the duration of smoking in pregnancy." "• Biological plausibility. Smoking during pregnancy reduced birth weight, a risk factor for SIDS. Further- more, maternal smoking in pregnancy may contribute to chronic fetal hypoxia, which may predispose to SIDS. Passive smoking in the infant's first year of life increases the risk of respiratory infections. Infeetions may result in pyrexia and lead to hyperthermia if the infant sleeps prone or is excessively dressed. An alterna- tive hypothesis is that maternal smoking may damage the fetal brainstem, resulting in an abnormal respira- tory response to noxious stimuli, hence increasing the risk of SIDS. This has some support from an animal model." "Thus all the major criteria for causation are met_"'

MAY 14„ 1993 [42] "Smoking, Passive Smoking and Smell," P. Hepper, Medical Science Research 20: 265-266, 1992 "In recent years there has been much interest in the effects of passive smoking, or environmental tobacco smoke, on health. As yet, however, there have been no investigations of the effects of passive smoking on smell. This experiment examined the effects of smok- ing and passive smoking on olfactory performance." "Subjects were divided into three groups. Smokers were individuals who smoked between 20 and 30 cigarettes per day, and had been smoking for at least 6 months. Nonsmokers were individuals who had never smoked and were kept out of a smoky environment for at least 10 h prior to the test. Passive smokers were individuals who had never smoked but for 1 h preced- ing the experiment had sat in a room with other smokers (the rest room of the university library)." "Subjects were taken into a well ventilated room and presented with odours in increasing strengths ... Subjects were asked to sniff deeply and inform the experimenter of what they smelt. The experimenter recorded the strength at which the subject correctly identified the odour." "45 subjects (15 per group) were tested using pepper- mint and 30 (10 per group) using lemon. Smokers were tested 5 min after finishing their last cigarette and passive smokers 5 min after leaving smoky environment." "Smoking exerted a highly significant effect on olfactory performance.... [S]mokers required a stronger concentration to identify the odours than both passive smokers and non-smokers. Passive smokers required a stronger concentration than nonsmokers." "To examine the `permanence' of the deficit caused by smoking, two further experiments were carried out using peppermint as the stimulus.... For the first group, smokers and passive smokers were tested I h after finishing their last cigarette or 1 h after leaving the smoky atmosphere, respectively. In the second group, smokers and passive smokers were tested 24 h after finishing their last cigarette or leaving the smoky atmosphere, respectively." "There was a highly significant effect of smoking. As with the previous experiment, smokers were poorer at identifying the odour than passive smokers, who were in turn worse than non-smokers." A-9 "[One hour] refraining from smoking or being out of a smoky environment had little effect on olfactory performance. However, for passive smokers 24 h out of a smoky environment returned'their olfactory perfor- mance to normal. No recovery of performance was observed for smokers." "The mechanism of smoke-induced deficits in olfactory performance has yet to be elucidated. It is possible in these studies that different mechanisms operated in groups of smokers and passive smokers. The reduction in performance of passive smokers may have been due to a short-term habituation effect, whereas the effects in smokers resulted from more permanent alterations in the olFactory mucosa or receptor cells, which would correspondingly take longer to reverse." ETS ExPOSVRE AND MONITORING [43] "Toxicology of Environmental Tobacco Smoke," M J. Reasor. In: Taxicology of Combustion Pnvd- ucts. L Manzo and D.F. Weetman (eds.). Pavia, Fondazione Clinica del Lavoro, 71-76, 1992 "Environmental tobacco smoke (ETS) is a complex and dynamic mixture of partides and gases which has been poorly characterized. Most experimental research has involved study of sidestream smoke rather than ETS, therefore, such results are difficult to interpret relative to human exposure." "Biological markers, including cotinine in biological fluids and DNA and protein adducts, have been utilized to assess exposure to ETS; however, none has been identified that can serve as a quantitative surro- gate for ETS. As a result of the paucity of information regarding ambient ETS characterization and exposure assessment, it has been difficult to evaluate the possible toxicological effects of ETS on humans." "Toxicological aspects concerning ETS exposure in humans are an area of ongoing debate and controversy. A number of reports have appeared alleging that chronic exposure to ETS results in adverse health effects in children and adults. A body of literature exists which has provided strong scientific reasoning in dispute of that conclusion. The principal reason for this controversy involves the nature of the human studies which have been almost exclusively by epide- miological procedures. Epidemiology is notoriously

A-10 weak at establishing causal relations at the low relative risks reported in studies involving ETS exposure." "It is unlikely that this controversy will be resolved by dependence on further epidemiological studies; alternative approaches will have to be utilized including studies using animals and 'in vitro' systems. In contrast to the abundance of epidemiological studies concern- ing ETS exposure, virtually no relevant information exists on the effects of ETS in animals and 'in vitro' systems. In studies using animals, the protocols generally have involved exposure to only sidestream smoke and at levels that are unrealistically high com- pared to ambient exposure to ETS. As a result, it is difficult to interpret the results of these studies in the context of human exposure. Increased emphasis in ETS research should be placed on developing and utilizing whole animal and 'in vitro' exposure systems and proto- cols utilizing conditions simulating ambient exposures." "It has been suggested that ETS is just a dilute form of the mainstream smoke inhaled by the active smoker, and therefore, in attempting to understand the possible effects of ETS, it is valid to extrapolate from what is known about active smoking. There is no evidence to support such an assertion. While mainstream smoke is highly concentrated, and its properties are rather-well characterized, ETS is exceedingly more dilute and far more dynamic. Thus it seems apparent that compari- son of ETS exposure to active smoking in a toxicologi- cal context is of little value." INDOOR AIR QUALITY [44] "Priority Among Air Pollution Factors for Preventing Chronic Obstructive Pulrnonary Disease in Shanghai," X. Tao, C.J. Hong, S. Yu, B. Chen, H. Zhu, and M. Yang, The Science of the Total Environment 127: 57-67, 1992 "Chronic obstructive pulmonary diseases induding chronic bronchitis, asthma and emphysema, are some of the major causes of death in residents of Shanghai city proper where ambient air pollution is mainly from sulphur dioxide (SO) and inhalable particulates and indoor air pollution is mainly from the use of coal for heating and/or cooking. The problems that city environmental protection planers face arc how impor- tant these exposures are in relation to COPD in local residents and which factor should be controlled ETS/IAQ REPORT, ISSUE 47 urgently. The purpose of our study is to determine the control priority among ambient SO2, IP and indoor use of coal to prevent COPD in residents of the city." "Distribution of ambient SOZ, and IP concentrations were described using a...imulation. When stratified by two extreme levels of ambient SO2 and IP and types of _ fuel used indoors, eight local area populations in four communities with different combinations of exposure levels were selected. In each community a local area population mostly using coal and one mostly burning gas was chosen. Chronic obstructive pulmonary diseases induding chronic bronchitis, asthma and emphysema, are a major cause of death in residents of Shanghai. The relationship between the three air pollution factors and their health effects were analyzed at the level of mortality, prevalence of symptoms of COPD, lung function and non.specific immunologic funetion." "Our study suggests that the indoor use of coal is more important than ambient SOZ and IP in relation to mortality and prevalence of COPD, pulmonary symptom, lung function and non-specific immuno- logic function in residents of Shanghai city. We recommend that the change of fuel from coal to gas or other types which produce less pollutants should be given priority over the effort to reduce ambient SO2 and IP, and this should be conducted first in the high ambient SO2 and/or IP areas." INDOOR AIR QUALITY [45] "Emissions of Volatile Organic Compounds from New Carpets Measured in a Large-Scale Environmental Chamber," A.T. Hodgson, J.D. Wooley, and J.M. Daisey, journul of the Asr and Wasu ManagementAssoeiation 43: 316-324, 1993 "Since little was known about the quantitative emissions of VOCs from carpets, this study was undertaken to measure chamber concentrations, emission rates and mass emissions of individual VOCs released by new carpets that are typical of the major types of carpets used in residences, school dassrooms and offices. Four carpets, induding two with SBR [styrene-butadiene rubber]' latex adhesive and two with other types of backings, were selected for study. Concentrations, emission rates and mass emissions of VOCs from samples of these carpets were measured under simulated indoor conditions in a 20 m3 environ-

MAY 14, 1993 mental chamber over a period of one week following the installation of a sample in the chamber. Duplicate chamber experiments were conducted for one carpet. Concentrations of selected compounds emitted by samples of the carpets in 4 L chambers were compared to the corresponding large chamber results to evaluate the usefulness of much smaller chambers. In addition, the concentrations and emission rates of VOCs emitted by a new carpet installed in a house were measured over a period of seven weeks." "The emission of VOCs from the study carpets were [sic], low relative to many other types of indoor sources, such as architectural finishes....Within this context of relatively low emissions, those compounds that had the highest emission rates or mass emissions were evaluated for their potential to produce health and comfort effects." "The eight dominant compounds identified...are styrene, 4-PCH [I4-phenylryclohexene], formaldehyde, vinyl acetate, 2,2,4-trimethylpentane, 1,2-propanediol,. 2-ethyl-l-hexanol, and BHT [butylated hyd'roxytolu- ene]: Of these, the most is known about the toxicity and irritancy of formaldehyde. Formaldehyde is a strong sensory irritant." "[S]ince other sources of formaldehyde are often present in buildings, the addition of a carpet source could result in concentrations that approach or exceed lower limits for irritancy. Only very limited data are available on the toxicity and irritancy of the other compounds at low concentrations." "Odor is an important factor that influences people's acceptance of products used indoors. The 4-PCH in SBR carpets is the source of the 'new carpet' odor which some people find objectionable. This odor, by itself, may be a source of complaints by consumers." "It is not clear whether the emissions of VOCs from carpets could produce health or comfort problems like those reported by some consumers. On the one hand, the emissions of TVOC from carpets are low relative to other sources of TVOC'that are commonly found in buildings. On the other hand, the potencies of differ- ent VOCs may vary over a number of orders of magnitude as evidence by the ranges of Threshold Limit Values for industrial exposures to chemicals, sensory irritancy as measured by the mouse bioassay and odor thresholds. New SBR carpets are likely to produce an odor for a period of several months due to A-I1 the persistent emissions of 4-PCH. With the exception of formaldehyde, only very limited data are available on the irritancy and toxicity of the compounds emitted by carpets. However, it is possible that several of the dominant compounds, in additional to formaldehyde, are sensory, and possible respiratory, irritants at relatively low concentrations. Therefore, it would be of value to determine the sensory and respiratory irritancy of these compounds, as well as their neurotoxicity; using appropriately sensitive tests." SMOKING POLICIES AND RELATED ISSUES [46] "Clean Indoor Air Legislation, Taxation, and Smoking Behaviour in the United States: An Ecological Analysis," S.L Emont, W.S. Choi, T.E. Novotny, and GA. Giovino, Tobacco Control2: 13-17, 1992 "[S]tatewide smoking restrictions and increases in cigarette excise taxes represent two potentially powerful public health tools that may influence smoking behaviour. This investigation examined the association of state clean indoor air laws and state excise taxes on cigarettes with these measures of smoking behaviour: current smoking prevalence, proportion of quitters, and consumption of cigarettes per head." "A1150 states and the District of Columbia were categorized according to the scope of their clean indoor air law in 1989. Such laws ranged from nominal policies, in which smoking was regulated in three or fewer public places, to extensive policies, in which smoking was regulated in four or more public places plus restaurants and private workplaces." "[S]moking prevalence was inversely related to the degree of restriction of the clean indoor air policy. The average smoking prevalence was 28% in states without dean indoor air laws and 24% in states with extensive clean indoor air laws. Average cigarette consumption per head, following a pattern similar to that of smoking prevalence, was about 119 packets in states without clean indoor air laws and 105 packets in states with extensive clean indoor air laws. The proportion of smokers who had stopped smoking (quitters) was positively associated with the scope of the clean indoor air policies. The average proportion of quitters was 44% in states without clean indoor air policies and 50% in states with extensive clean indoor air policies."

A-12 "Although we could not test the causal relation between clean indoor air legislation and measures of smoking behaviour in our study, our multivariate analyses indicated that either moderate or extensive clean indoor air laws (but not nominal or basic dean indoor air policies) were associated with a lower smoking prevalence and a higher proportion of quit- ters. Even though the primary purpose of implement- ing clean indoor air policies is to protect the non- smoker from exposure to environmental tobacco smoke, such policies - particularly comprehensive policies - may have an impact on smoking behaviour." "The impact of clean indoor air laws and cigarette excise taxes on smoking behaviour deserves further evaluation. In addition to dean indoor air legislation and excise taxes, there are a number of other public health strategies that can be used to reduce tobacco consumption globally. These include regulating tobacco advertisements and promotions, using mass media in a coordinated anti-smoking campaign, and providing school health education programmes on smoking....Only through coordinated global tobacco control initiatives will we curtail what is surely ex- pected to be a worldwide epidemic of smoking-related morbidity and mortality." ETS/IAQ REPORT, ISSUE 47

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