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6 DRAFT ENVIRONMENTAL TOBACCO SMOKE: A COMPENDIUM OF TECHNICAL INFORMATION INDOOR AIR DIVISION OFFICE OF ATMOSPHERIC AND INDOOR AIR PROGRAMS OFFICE OF AIR AND RADIATION U.S. ENVIRONMENTAL PROTECTION AGENCY WASHINGTON, DC 20460

PREFACE This compendium of technical information on Environmental Tobacco Smoke (ETS) is intended to be useful for a diverse audience, including: decision-makers such as labor and management officials concerned with workplace exposures, public health officials and corporate medical directors who are concerned with making health policy recommendations, educators, industrial hygienists and safety officers, ETS researchers, indoor air pollution investigators, and legislators who are considering legislation to restrict smoking in workplaces, restaurants, and public access buildings. There are ten chapters in this compilation, including health effects of active smoking in adults and passive smoking in children and adults, ETS exposure and dosimetry, comfort aspects, ventilation and ETS, public beliefs about the harm of ETS and attitudes toward controls, and effective workplace smoking policies, each of which is aimed at a somewhat different audience. Although not all chapters will appeal equally to such a varied group, it is hoped that the technical information in this document, written by experts in the field, will provide information necessary to allow the public, government agencies, and the building industry, to make well-informed choices regarding exposure to ETS. This technical document represents a coordinated effort jointly sponsored by the Environmental Protection Agency (EPA), the National Cancer Institute (NCI), the Office on Smoking and Health (Centers for Disease Control), the National Heart, Lung, and Blood Institute, and the Office of Disease Prevention and Health Promotion (Department of Health and Human Services). 2

Chapter 1."Passive Smoking -- Beliefs, Attitudes, and Exposures in the United States" ! Thomas E. Novotny ............................................6 Chapter 2. "Effects of Smoking on Smokers" Donald Shopland ............................................22 Chapter 3. "The Odor and Irritation of Environmental Tobacco Smoke" William S. Cain ............................................29 Chapter 4. "Environmental Tobacco Smoke and Cancer" Jonathan M. Samet ..........................................40 Chapter 5. "Measuring Exposure to Environmental Tobacco Smoke" Brian P. Leaderer .........................................53 Chapter 6. "Environmental Concentrations of ETS" John McCarthy, Elizabeth Miesner, and John D. Spengler .....65 Chapter 7. "Exposure Assessment in Passive Smoking" James L. Repace ...........................................79 Chapter 8. "Absorption of Smoke Constituents by Nonsmokers" Dietrich Hoffman, Klaus D. Brunnemann, and Nancy J. Haley...... : ...................................95 Chapter 9. "Passive Smoking and Daycare" Glen Bennett ...............................................117 Chapter 10. "No Smoking Policies at the Worksite: A look at what companies are doing today" Ruth Behrens ..............................................135 Chapter 10 Appendix: "Economic Justification for Worksite Smoking Policies" Ruth Behrens ..............................................172 ~ ~ 3 0 CA N .~ W

i INTRODUCTION In 1986, the Surgeon General and the National Research Council, the latter under contract to EPA, examined the health effects of the breathing of Environmental Tobacco Smoke (ETS) by nonsmokers (also known as involuntary or passive smoking). They agreed that passive smoking caused lung cancer in nonsmoking adults, caused increased rates of respiratory infections in children, caused acute noxious effects in many nonsmokers, and was a major contributor to indoor air pollution. Subsequent to the publication of these documents, smoking restrictions began to proliferate. However, a number of diverse technical questions arose concerning public attitudes toward smoking restrictions, health and comfort effects, factors affecting exposure, measuring environmental concentrations of ETS, effects of ventilation on ETS and indoor air quality, nonsmokers' uptake of tobacco combustion products, and corporate experience in effective smoking policy, all comprise chapters in this compendium. In the interest of providing answers to this complex of questions, this technical compendium was commissioned. A brief summary of each chapter follows. Chapter 1 discusses the results of national surveys of trends in public attitudes toward ETS and restrictions against smoking, particularly in the workplace. It is concluded that there is a trend toward restrictions on smoking in the workplace, accompanied by widespread public acceptance. Chapter 2, in a series of simple bar charts, describes the effects of smoking on smokers, including cancers, cardiovascular disease, and respiratory diseases. It is graphically illustrated why cigarette smoking is now recognized as the Nation's single largest cause of premature death and disability. Chapter 3 explores the effects of ventilation on the perception of odor and irritation from ETS in both nonsmokers and smokers, and shows that although most attempts to control ETS have relied on ventilation and air cleaning, they have limitations. Chapter 4 discusses environmental tobacco smoke as a cause of lung cancer in nonsmokers, and discusses the conclusions of the World Health Organization, the National Research Council, and the U.S. Surgeon General on this issue. Chapter 5 treats the methods of assessing nonsmoker's exposure to environmental tobacco smoke by atmospheric markers, and the measurement of these marker substances in indoor air. Chapter 6 reviews studies of the concentrations of certain ETS constituents observed in homes, offices, and other locations by personal exposure monitors. It is concluded that ETS is the primary contaminant contributing to respirable particles and m 4 ~ O OD !-~ ~ »'a

contributes substantially to other indoor contamininants such as benzene, carbon monoxide, and others. Chapter 7 demonstrates how ventilation effects concentrations of tobacco smoke, and gives equations for the estimation of indoor environmental concentrations of respirable tar particles from ETS based on ventilation rates, number of smokers, and room size. Chapter 8 provides a detailed treatment of the absorption and metabolism of tobacco combustion products by nonsmokers. It shows that absorption has been conclusively demonstrated by studies of nicotine and its metabolite, cotinine, in the body fuids of nonsmokers, and that such biomarkers represent a reliable specific method for assaying the level o.f uptake of ETS. Chapter 9 analyzes the effects of passive smoking on young children and infants. The conclusion is reached that day care workers must be educated about the possible compounded effect of passive smoking and day care attendance on the increased risk of respiratory disease among infants and toddlers. Chapter 10 examines features of corporate smoking policies in the workplace, with attention to benefits, incentives, employee and union involvement, and education. Case histories are discussed involving several major corporations, detailing problems encountered and successes. In an appendix an economic rationale for worksite smoking policies is given, with the conclusion that smokers burden employers with excess costs (in some cases 100% higher) related to their smoking relative to nonsmokers. GO 11 5 OD O OD N ~ N

CHAPTER 1 PASSIVE SMOICING--BELIEFB, ATTITUDES, AM EXPOSURES IN THE UNITED STATES Thomas E. Novotny, MD Chief, Program Services Activity Office on Smoking and Health Centers for Disease Control Introduction The relationship between public attitudes, policies, and exposure to certain health hazards is complex. With the release of the *18th Surgeon General's report on smoking and health, "The Health Consequences of Involuntary Smoking," (US DHHS 1987) public attention on the issue of Environmental Tobacco Smoke (ETS) was more strongly focused than ever before. For many years, however, pollsters, the tobacco industry, and the health promotion community have surveyed the public concerning attitudes toward ETS and toward restrictions against exposure to ETS. The Surgeon General's Report described data from several of' these surveys as well as results from evaluations of worksite and local policy changes. Additional detailed data on public beliefs and attitudes toward smoking in general are found in the 1989 Surgeon General's Report: Reducina the Health Conseauences of Smokina -- 25 vears of Proaress. Recently, surveys have also included both questions on beliefs about the harmfulness of ETS to the nonsmoker and on respondents' reported exposure to ETS. In addition to such individual exposure data, surveys of worksites and of personnel managers have provided information about restrictions on ETS exposure to workers. Because changes in public attitudes toward ETS usually precede laws or policies regarding ETS exposure (US DHHS 1987), an examination of trends in these data over time is useful. This section will consider several different nationally-based data sets andsummarize the most important findings from them. Survevs of Public Beliefs. Attitudes, and Exflosures The surveys reported in this section are summarized in Table 1. 6

These surveys may report discrepant results. Most discrepancies can be explained by the differences in methodology, especially in the ways that questions are worded. Nonetheless, comparisons between surveys are useful. The only Roper Survey commissioned by the Tobacco institute available to the public was done in 1978. The narrative from this study included data from 1974 and 1976 also. Additional surveys on public attitudes have been performed by Roper or other agencies for the industry, but many of these are not available. A recent Tobacco Institute-sponsored survey of attitudes toward government policies conducted by Hamilton, Frederick, and Schneider has been made available and is reported.. The 1974-1978 Roper surveys permit comparisons of data collected for the tobacco industry with similar data collected in the 1970s by the Office on Smoking and Health (formerly known as the National Clearinghouse on Smoking and Health). Additional national surveys of public attitudes and beliefs were performed in the 1980's by the Gallup Organization and the Louis Harris Co. National surveys of worksites were also carried out in the 1980's in conjunction with increasing restrictions and laws against smoking in public places throughout the United States (US DHHS 1987). These surveys, which indicate the degree to which workers may be protected from ETS exposure, permit comparisons with exposures reported by individual respondents in the 1986 Adult Use of Tobacco Survey (AUTS) of the Office on Smoking and Health. In addition, the 1987 Gallup survey of attitudes toward smoking in restaurants described public opinion about exposure in an additional, policy-relevant, nonworksite setting. The 1987 National Health Interview Survey of Cancer Epidemiology and Control collected information about respondents' actions in response to ETS exposure. Data Sources and Methodology Tobacco Industry Survevs Roper Surveys The Roper Organization conducted six biennial national opinion surveys for The Tobacco Institute between 1966 and 1978. The *1974, 1976, and 1978 surveys focused on the passive smoking/non-smoker's rights issue (Roper 1978), whereas all six surveys dealt with public attitudes towards the smoking and health issue, towards the tobacco industry itself, and towards *goverriment regulation of tobacco. The surveys were telephone-based, but information about the exact methodology, sample sizes, and response rates is unavailable. In December 1988, the Tobacco Institute sponsored a National adult 7

telephone survey of 1500 persons which was conducted by Hamilton, Frederick, and Schneiders (Hamilton, Frederick and Schneiders, 1989). This survey asked about various public policy issues and was to measure levels of support on governmental policy on smoking. The respondents were asked what they thought about restrictions on smoking in restaurants and worksites. The results were not reported by smoking status of the respondents, but 401 (27%) of the respondents were smokers. The response rates were not reported. Other Public Opinion Surveys Gallup Surveys Gallup Poll results have been- published monthly by the Gallup organization since 1965. Surveys are either personal interviews or by telephone, with a population-based sample of at least 1000 adults, >_ 18 years of age. The sampling error for overall responses is reported to be no more than ±21 (Gallup Report 1987). In addition, Gallup surveys may be commissioned by a variety of organizations. The surveys reported here were commissioned by the American Lung Association (1983, 1985, 1987, and 1989) and The American Cancer Society (1988) to study both the prevalence of smoking and public opinions regarding smoking issues. An additional Gallup Survey was -commissioned by the National Restaurant Association (1987) to obtain public opinion on smoking in restaurants. The 1989 Gallup Survey sponsored by the American Lung Association did not ask respondents about their smoking status. Harris Poll Louis Harris and Associates have performed eight national surveys between 1974 and 1987 using probability samples of adults aged 18 and older. These surveys were conducted on behalf of various organizations, including Prevention magazine and Pacific Mutual Life Insurance Co., to ascertain health practices in Americans. In 1987, 1250 persons were also asked about regulating smoking in public places. Government Sponsored Surveys Adult Use of Tobacco Surveys (AUTS) The Office on Smoking and Health (formerly, National Clearing House on Smoking and Health) commissioned surveys of adult smoking behavior, attitudes, and beliefs beginning in 1964. These surveys oversampled smokers, but final results were weighted to represent the United States resident population aged 21 years and older (1964, 1966, 1970, 1975). The 198*6 AUS oversampled smokers and also collected data from persons aged 17 and older. The final data in this survey were weighted to reflect the educational, regional, 8

racial, and age distribution of the U.S. population based on the 1986 Current Population Survey of the U.S. Bureau of the Census. More detailed information on attitudes, beliefs, and exposure regarding ETS was collected in this survey. National Health Interview Survey The National Health Interview Survey of Cancer Epidemiology and Control (NHIS-CEC) collected data in-person from 22,000 adults _>18 years of age in households throughout the United States. The data are weighted to reflect the entire U.S. population, and the overall response rate for NHIS-CEC was 82%. Respondents were asked about the harmfulness of ETS and about attitudes toward passive smoking. These included perceived annoyance and whether smoking should occur inside public places. Nonsmokers were asked about their actions in response to smokers' lighting up in their presence. Other Surveys Worksite Surveys Several surveys of worksites and businesses have been carried out in the last several years. These are described in detail in The 1986 and 1989 Surgeon General's Reports (U.S. DHHS 1987, 1989). The Bureau of National Affairs and the American Society for Personnel Administration (ASPA) conducted a mail-in questionnaire survey of ASPA members. Six hundred twenty-three respondents reported on activities related to smoking in the workplace. The response rate was 54%. A similar survey had been carried out in 1986 on 662 businesses, and results on the presence or absence of restrictions were comparable. In- 1988, the Office of Health Promotion and Disease Prevention (OHPDP) of the United States Public Health Service reported on worksite health promotion activities, including smoking control. The survey was carried out in 1985 on a sample drawn from the Dun and Bradstreet list of businesses. Using a telephone interview, 320 worksites with 50-90 employees and 1,038 worksites with 100 or more employees, drawn from a probability sample based on geographic region, size of firm, and industry type, were surveyed. Questions about smoking restrictions were included. In December 1984, the American Board of Family Practice (ABFP) sponsored a National telephone survey of 1007 adults _>18 years of age and of 303 Family Physicians conducted by Research and Forecasts, Incorporated. The results were published in a report entitled, Riahts and Responsibilities: Healthcare Ovtions. Questions were asked regarding beliefs about the harmfulness of ETS, the rights of smokers and non-smokers, and whether smoking restrictions are effective in stopping or discouraging smoking. The final sample response rates were 41% for the general public 9

and 37% for physicians. Data for the general public portion of this survey were weighted to reflect the 1985 U.S. Census for 1985. The physicians surveyed represented a random sample of U.S. Family Physicians. Results of Surveys Perceived Harmfulness of Environmental Tobacco Smoke Although the questions asked on the various surveys regarding ETS may differ somewhat, comparisons between surveys are still useful. The Roper Surveys asked questions regarding harm and annoyance caused by ETS. All AUTS surveys asked about annoyance caused by ETS, but only the 1986 AUTS asked if respondents believed that ETS was harmful to the nonsmoker. The 1983 and 1988 Gallup Surveys asked if respondents believed that smoking is hazardous to the health of nonsmokers. The 1978 Roper Survey and both the 1986 AUTS and 1988 Gallup surveys provide interesting information on the change in public beliefs about the harmfulness of ETS to the nonsmoker over the last several years. The 1985 ABFP Survey asked both adults and physicians if they believed nonsmokers are harmed by breathing in the smoke of others in the same room. Table 3 shows the responses to survey questions regarding harmfulness caused by ETS. Between 1974 and 1986, the percentage of smokers who believed that ETS is harmful to the health of the nonsmoker more than doubled. In 1974, most nonsmokers believed that ETS is harmful to health in general, and the percentage of those who held this belief increased substantially to almost 90% in 1989 and 1988. Overall, the percentage of persons who believe ETS is harmful to health increased from 464 in 1974 to 81% in 1988. In an additional question on the 1986 AUS, 69% of non-smokers (62% of former smokers and 74% of never smokers) felt that ETS is harmful to their own personal health. The resluts of the 1989 Gallup poil suggest that there is even stronger belief in the harm of ETS to pregnant women and children. These data suggest that there has been a major change in the perception of ETS as a health hazard over the last decade. Annoyance Caused by Environmental Tobacco Smoke The AUTS surveys show an increasing trend in the percentage of respondents who are annoyed by ETS, (from 46% to 69% of all respondents between 1964 and 1987) (Table 3a). Data regarding annoyance to ETS from Roper Surveys other than the 1978 survey are not available. However, the results of the 1978 Roper Survey report that 60% of nonsmokers and 5% of smokers were annoyed by the smoke of others. These data suggest that increasingly fewer Americans are tolerant of ETS exposure. The results of the 1987 NHIS-CEC indicate increased annoyance to ETS as well (Table 3a). 10