Tobacco Documents Online

THESECRETAR¥ OF°HE/'G.TH AND HUMAN SERVICES DEC 1.5 IS The Honorable George Bush President of the Senate Washington, D.C. 20510 Dear Hr. President: It is my pleasure ~o transmit ~o the Congress the 1986 Surgeon Generalts Report on the health consequences of sm~kln~, as mandated by Section 8(a) of the Publlc Health Cigarette SnDking Act of 1969. The current volume, entitled The Hea~th...Consequences" 6f In.vol.un~r~ S~kinE, examinee the scientific evidence on the health effects resultin8 f~omnonsmoker exposure to environmental tobacco The issue of whether or ~ot tobacco snDke ~s carcinogenic for humans was conclusively resolved more than 20 years ago when the first report on smoking and health was issued in 196~. Based on the current report, the judgment can now be nmde that exposure to envlzonmental tobacco smoke can cause disease, includln8 lung cancer, in nonsmokers. It is also clear that s~mple separation of smokers and nonsmokers within the same alrspacemay reduce but cannot ellnL~na~e nonsmoker e~posure to environmental tobacco smoke. The report also revle~s an extensive body of evidence which establishes an increased'rlsk of respiratory illness and reduced lun8 function ~n infants and very young children of parents who ~ke. This effect is more pronounced if both parents smoke than if only one parent smokes. As a physician, I believe that parents should refrain f/om smoklnE around small children both as a means of protectlnE ~helr children's health and to s~t a ~ood example for ~he child. Today, only 30 percent of the adult population in Ehe United States are smokers--the lowest level of smoking in the country since World ~ar If, reflectlnE tha~ the great majority of the population has never smoked or has successfully qui~. Accompanying this decllne in overall prevalence of cigarette smoking has been an increased concern for pro~ecting the health and well belnE of nonsmokers, as e¢idenced by the number of la~s and regulations restricting smoking in public places. Today, A0 Staees and the District of Columbia have enacted some form of legislaeion ~o restrict emoklnK in public. IncreasinEly, these l~s pertain to protecting nonsmokers in many different settings, including the workplace. TI22531721

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E~goed for Publication and Broadcasting I~1o1 to be released before 10:00 a.m. EST December 16~ 1986

THE HEALTH CONSEQUENCES OF INVOLUNTARY SMOKING a report of the Surgeon General 1986 U.S. DEPAR'IMENT OF HEALTH AND HUMAN SERVIGES Poidlc Health Centers I~ Dlazzse ConUol Cenler |ix Hzallh Promotion and Educat|o~ Office eli Smoking and Health Freaky|lie, Maryland 20857

PREPUBLICATION EDITION This copy Is Issued as a prepubllcallon edllion co~dalnlng no subJec! Index. A final edition wllh Index will be available approximately eight .weeks from date of release. FOREWORD The dat=l reviewed in 17 previous U.S. Public Health Service reports on the health consequences of smoking have conclusively established cigarette smoking as the largest single preventable cause of prenmture death and disability in the United States. The question whether tobacco smoke is harmful to smokers was answered more than 20 yeal~ ago. As a result, ===any sclentists began to quest=mr whethe," the low levels or exposure to environmental tobacco smoke (ETSI received by nonsmokers could.also be harmful. The current Report, The Health Consequences of Involuntary 'Smoking. examines the evidence that even the lower exposure to smoke received by the nonsmoker carries with it a health risk. Use of the tern= "involuntary smoking" denotes that Ibr many nonsmokers, exposure to E['S is the result of an unavoidable consequence of being in proxhnily to smokers, it is the first Report in the health conseque=)ccs of smoking series to establish u health risk due to tobacco sm,ke exposure for individuals uther than the smoker, and represents the work of more than 60 distinguished physicians and scientisls, both in this country and abroad. After cart;ful examination of the available evidence, the following overall conclusions can be reached: 1. Involuntary smoking is a cause or disease, including lung canct,r, in healthy nonsmokers. 2. The children of parents who smoke, compared with the ehihh'en of nonsmoklng parents, have an increased frequency of" respiratory infections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the lung nlatu res, 3. Siml,le sel)aration of smokers and nonsmokers within the same air space may reduce, but does not eliminate, exposure or n.nsmokers to environmental tobacco smoke. l~Xl}O,'~m'~, I.o el=vil'onn~ental tobacco smoke occurs at home, at the work,~itc, in public, m~d in other places where smoking is permitted. vii

The quality of the indoor environment must be a concern of all who control and occupy that environment. Protection of individuals from exposure to environmenlal tobacco smoke is therefore a responsil~ili- ty shared by all: As pareats and adults we u|ust children by not exposing .them smoke. protect the health of oui' to eaviro=mzeutal tobacco As employers and employees we must ensure that the act of smoking does not expose the nonsmoker to tobacco smoke. For smokers, it is their responsibility to assure that their behavior does not jeopardize the health of ot hers. • For nonsmokers, it is their responsibility to provide a support- ive environ meat for smokers who are atteml)ti==g ~o stop. .. Actions taken b~ individuals, employers, and employee organiza. tions reflect the growin~ concern for protecting nonsmokers. The number o~ laws and regnlations enacted at the natioual, State, nnd local level governing smoking in public has increased substantially over the past 10 years, and surveys conducted b~ numerous organizations show stron~ public support for these actions among both smokers and nonsmokers. As a Nation, we have made substantial progress iu addressing the enormous toll inflicted by active smoking. ~1]~='~ to improve nn4 protect individual health must not only be contlm=e~ but strength- shed. On the basis o~the evidenca lu'ese~=ted in this Report, it is clear that actions to protect mmsmokers from £1'S exposm~ not only ==re warranted but are essential to protect public health. Robert E. Windom, M.D. Assistant Secretary Ibr Health PREFACE This, the 1986 Report of the Surgeon General, is the U.S. Public Health Service'a 18th in the health consequenceb of smoking series and the 5th issued during my tenure as Surgeon General. Previous Iteports have documented the tremendous health burden to society from smoking, particularly cigarette smoking, The evi- dence establishing cigarette smoking as the single largest preventa- ble cause of premature death and disability in the United States is overwhelming--totaling more titan 50,000 studies from dozens of cultures. Smoking is now known to be causally related to a variety of cancers in addition to lung cancer; it is a cause of cardiovascular disease, particularly coronary heart disease, and is the major cause of chronic.=~bstructive lung disease. It is estimated that smoking l= responsible for well over 300,000 deaths annually in the United States, representing approximately 16 percent of all mortality. Thirty years ago, howev.er, the scientific evidence linking smoking with early death and disability was more limited, By 1964. the year the Advisory Committee to the Surgeon General issued the first report on s.moking and health, a substantial body of evidence had accumulated upon which a judgment could be made that smoking was a cause of disease in active smokers, Subsequent reports over the last 20 years have expanded our understanding and knowledge about smoking behavior, the toxicity and carcim~genicity of tobacco smoke, and the specific disease risks resulting frnm exposure to this agent. This itelswt is the first issued since 1964"that identifies i~ chronic disease risk resulting from exposure to tobacco smoke for individuals other than smokers. It is now clear that disease risk due to the inhalation t~f tobacco smoke is n~t limited to the individual who II smoking, but can extend to those who inhale tobacco smoke emitted into the air. This Report represents a detailed review of the health effects rost, ltlng front nonsmoker exposure to environmental tobacco smoke (l~rS). ETS is the combination of smoke emitted from a burning tol~acco product between puffs (sidestream smoke) and the smoke exhaled by the smoker. The 1986 Report, The Health Consequem.os of Involuntary Smoking, is a critical review of all the available scientific evidence pertaining to the health effects of ETS exposure on nonsmokers. The term "involuntary smoking" is used to

note that such exposures often occur as an unavoidable cons.equcace o{' being in close proximity to smokers. Lung Cancer and Environmental Tobacco Smoke The appropriate frame:work for an examination of the lung cancer risk I'rom involuntary smoking is that of a low-dose exposure to a known hmnaa carcinogen. Over 30 years of rescarch have conclu- sively established cigarette smoke as a carcinogen. This Relmrt presents evidence that the chemical composition of sidestrcam smoke is qualitatively similar to the mainstream smoke inhaled by the active smoker, and that both mainstream and sidestream smoke act as carcinogens in bioassuy systems. Data related to envlronmen- tol levels of tobacco smoke constituents and from measures of nicotine absorption in nonsmokers suggest that nonsmokers are exposed to levels of environmental tobacco smoke that would be" expected to generate a lung cancer risk; epidemiologlcal studies of populations exposed to I','TS hdvd documented an increased risk for lung cancer in those nousmokers with increased exposure. It is rm'e to have such detailed exposure data or humau eplde.mio- logic studies on disease occurrence when attempting to evaluate" the risk of low-dose exposure to an agent with established toxicity at higher levels of exposure. The relative abundance of data reviewed in this Report, their cohesiveness, and their biologic plausibility allow a judgment that i~woluntary smoking can cause lung cancer in nonsmokers. Although the number of lung cancers due to involun- tary smoking is smaller than that due to active smoking, it still represents a nmnber sufficiently large to generate substantial public health concern. It is certain that a substantial proportion of the lung cancers Lhat occur in nonsmokers are due to ETS exposure; however', more complete data on the dose and variability of smoke exposure in the nonsmoking U.S. population will be needed before a quantitative estimate of the number of such cancers can be made. Children and Infants This Report also documents a relationship between parental smoking and the respiratory health of infants and children (under 2 years of age). Infants of parents who smoke have an increased risk of hospitalization for bronchitis and pneumonia when compared with infants of nonsmoking parents. There is a relationship between parental smoking and an increased frequency of respiratory symp- toms in children. A slower rate of growth" in lung run(~tion has been observed in children of smoking parents. In ninny studies, if both X parents ,qmoke, a stronger relationship exists than if only ohe parent smokes. What fut~re respiratory burden these findings may represent for these children later in life is not known. As a former pediatric surgeon, 1 .trongly urge parents to refrain from smoking in the presence of children as a means of protecting not only their childrcn's ct=rrent health sl~atus but also their own. Diseases Other Than Lung Cancer Several sl.udies have provided data ou the relationship between ETS and cm~cers other than lung cancer and on ETS exposure and cardiovascular disease. However, further research in these areas will be required to determine whether an association exists between ETS exposure and an increased risk of developing these diseases. , Policies Restricting Smoking In Public Places The growl.h in our understanding of the disease'rlsk associated with involu,ztary smoking has been accomlmnled by a change in the social accepl.ability of smoking and by a growiag body of legislation, regulation, and voluntary action that addresses where smoking may occur in puhlic. Forty States and the District of Columbia now have some form o1" legislation controlling or restricting smoking in various public sctti,zgs. Some StaLes limit smoking to only a few designated areas; however, States are increasingly developing and implement- ing comprelzensive legislation that restricts smoking in many public settings, including the workplace. Nine StaLes have restrictions that cover smvking not only by public employees but also by employees in the prlwtte sector. No systematic evaluation of the effects these measures may h&ve 'on smoklnl: behavior has been conducted, but there is little doubt that strong public sentiment exists for implementing such restric- tions. A number of national surveys conducted by voluntary health organiT~tions, government agencies, and even the tobacco industry have documented that an overwhelming majority of both smokers and nonsmokers support restricting smoking in public. Public Hbalth Policy and Involuntary Smoking The 1986 Surgeon General's Report on the Health Consequences of [nvolnntary Smoking clearly documents that nonsmokers are placed at increased risk for developing disease as the result of exposure to enviromnental tobacco smoke. Critics olten express that more research is required, that certain • studies aro flawed, or that we should delay action until more conclusive proof is produced. As both a physician and a public health

official, it is my judgment that the time for delay is past; measurc~ to protect the public health are required now. The scientific case against involuntary smoking as a health risk is more than sufficient to justify appropriate ron~edial action, and the goal of. any remedial action must be to protect the nonsmoker from environmental tobacco smoke. The data contained in this Report on the rapid diffusion of tobacco smoke throughout an enclosed environment suggest that separation of smokers and nonsmok.ers in the same room or in different rooms that.share the same ventilation system may reduce I,,~I'S exposure bat will not eliminate exposure. The responsihility to protect the safety of. the indoor environment is shared by all who occupy or control that environme==t. Changes in smoking policies regarding the workplace and other environments |~ecessitated by the data preseated in this Rel~rt should not be designed to punish the smoker. Successful implementa- tion of. protection for the nonsmoker requires the support and cooperation of. smokers, nonsmokers, management, and employees and should be developed through a cooperative effort of all groups affected. In addition, changes are often more elf.active when suplmrt and assistance is provided for the smoker who wants to quit. Cigarette smoking is an addictive behavior, and the individual smoker mast decide whether or not to continue that behavior; however, it is evident fi'om-the data presented in this volume that the choice to smoke cannot interfere with the nonsmokers' right to breathe air free of tobacco smoke. The right of smokers to smoke ends where their behavior affects the health and well-being of others; furthermore, it is the smokers' responsibility to ensure that they do not exlmse nonsmokers to the potential harmful effects of. tobacco smoke. C. Everett Keep, M.D. Surgeou General ACKNOWLEDGMENTS This Report was prepared by the Department of Hcalth and Human Services under the general editorship of the Office on Smoking attd Health, Donald R. Shopland, Acting Director. Manag- ing Editor was William R. Lynn, Acting Technical Information Officer, Office on Smoking and Health. Senior scientific editor was David M. Burns, M.D., Associate Professor of Medioine, Division of Pulmonary and CritiCal Care Medicine, tlniversity of California Medical Center, Sen Diego, San Diego, Calilbrnia. Consulting scientific editors were Ellen R. Gritz, Ph.D., Director, Division of Cancer Control, Jonson Comprehensive Cancer Center, University of Ca.llfornia, Los Angeles, Los Angeles, California; John H. Holbrook, M.D., Associate Professor of Internal Medicine, Department of Internal Medicine, University Hospital, Salt Lake City, Utah; and Jonathan M. Samet, M.D., Professor of Medicine, Department of Medicine, The University of New Mexico School of Medicine, AIb. uquerque, New Mexico. The following individuals prepared draft chapters or portions of the Report. Neal l~,nowitz, M.D., Sen Francisco General Medical Center, San Francisco, California A. Senia Btfist, M.D., Profe~or of Medicine, Departm.ent of Physlolo- bY, Oregon Health Sciences University, Portland, Oregon Charles Hiller, M.D., Pulmonary Division, University Hospital, Little Rock, Arkansas Dietrich Hoffmann, Ph.D., Associate Director, Naylor Dana Institute for Disc,as Prevention, American Health Foundation, Valhalla, New York lisa Hoffmann, Research Coordinator, Naylor Dana Institute for Disease l'revention, American tlealth Foundation, Valhalla, New York John It. lloidal, M.D., Director of Pulmonary Medicine, University of Tennessee Center for Ilealth Sciences, Memphis, Tennessee John McC~wthy, M.P.H., Harvard School of Public Health, Boston, Ma~s~tchusetts xlil

f Nancy A. Rigotti, M.D., Institute fvr the Study of Smoki~,g Behavior and Policy, John F. Kennedy School of Govermnent, Harvard University, Cambridge, Massachusetts Jonathan M. Samet, M.D., Professor of Medicine, Department of Medicine, The University of New Mexico School of Medicine, Albuquerque, New Mexico John Spongier, Ph.D., Harvard School of Public Health, Boston, Massachusetts Annetta Weber, Ph.D., Federal Institute of Technology, Zurich, Switzerland 'Scott T. Weiss, M.D., M.S., Associate Professor of Medicine, Chan- ning Laboratories, [larvard Medical School, Boston, Massachu- setts Anna H. Wu, Ph.D., Department of Preventive Medicine, Schm~l of Medicine, University of Southern California, Los Angeles, Califor- nia The editors acknowledge with gratitude tile following distin- gulshed scientists, physicians, and others who lent their support in the development of this Report by coordinating manuscript prepara- tion, contributing critical reviews of the manuscript, or assisting in other ways. Elvln E. Adams, M.D., M.P.H., Director, Health and Temperance" Department, General Conference of Seventh-Day Adventists, Washington, D.C. Stephen M. Ayres, M.D., Dean, School of Medicine, Medical College of Virginia, Richmond, Virginia David V. Bates, M.D., Professor of Medicine and Physiology, Department of Medicine, Acute "Care Hospital, University of British Columbia, Vancouver, British Columbia William J. Blot, Ph.D., Chief, Biostatistics Branch, Epidemiology and Biostatistics Program, Division of Etiology, National Cancer Institute, National Institutes of Health, Bethosda, Maryland. Benjamin Burrows, M.D., Professor of Internal Medicine, and Director, Division of Respiratory Sciences, The University of Arizo,na College of Medicine, Tucson, Arizona D. M. DeMarini, Ph.D., Genetic Toxicology Division, U.S. Environ- mental Protection Agency, Research Triangle Park, North Cm:o- lina Vincent T. DaVits, Jr., M.D., Director, National Cancer Institute, National Institutes of Ilealth, Bethesda, Maryland Louis Diamond, Ph.D., College of l'harmacy, University of Kentucky, Lexington, Kentucky Richard Doll, Cancer Epidemiology and Clinical Trials Unit, lmperl- ai Cancer Research Fund, The Radcliffe Infirmary, University of Oxford, Oxford, Englaud, United Kingdom xiv Manning Feinle~:, M.D., Dr.P.H., Director, National Center for Health SI.atistics, Office of tile Assistant Secretary for Health, Hyal.t.sville, Maryland Edwin Ik I"isher, Jr., Ph.D., Associate Professor, Department of psychology, Washlngtan University, St. Louis, Missouri William II. Foege, M.D., Executive Director, Task Force for Child Si~rvlval, Carter l~residential Center, Atlanta, Georgia Joseph F. Fraumeni, Jr., M.D., Associate Director for Epidemiology and Biosl.atistics, Division of Cancer Etiology, National Institutes of Health, Bethesda, Maryland Lawrenc.e {|arfinkel, M.A., Vice President for Epidemlol.ogy and Statistics, and Director of Cancer Prevention, American Cancer Society, New York, New York • R.A. Grlcsen|er, D.V.M., l'h.D., Director, Biology Division, Oak Ridge Natio,ml I,aboratory, Oak Ridge, Tennessee Michael, R. Guerin, Ph.D., Organic Chemistry Section, Analytical Chemistry, Oak Ridge National I,aboratery, Oak Ridge, Tennessee Jeffery E. I larris, M.D., Ph.D., Associate Professor, Department of Economics, Massachusetts Institute of Technology, Cambrldge, Massachusetts Millicent lliggins, M.D., Associate Director, Epldemlology and Biometry Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Takeshl llirayama, M.D., Director, Institute of Preventive On.coiogy, Shinjuku-ku, Tokyo, Japan Dwight Janerich, D.D.S., M.P.H., Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, .Connecticut Martin Jarvis, M.P.H., Senior Clinical Psychologist, Addiction Research Unit, Institute of Psychiatry, London, England, United Kingdom Brian P. Lenderer, Ph.D., M..P.H., AssOciate Fellow, John B, Pierce Foundati~m Laboratory, Associate Professor, Ddpartment of Epide- mlology ~md Public Health, Yale University School of Medicine, New 1 laven, Connecticut Charles L. I,eMalstre, M.D., Prdsident, University of Texas Systems Cancer C~mter, Houston, Texas Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Donald lan Macdonald, M.D.~ Administrator, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland James S. Marks, M.D., M.P.H., Assistant Director for Science, Center for llealth Promotion and Education, Centers for Disease Control, Atlanta, Georgia James O. Mason, M.D., Dr.P.H.,Directer, Centers for Disease Con- trol, Atla,~ta, Georgia XV

J. Michael McGinnis, M.D., Deputy Assistant .Secretary for Health (Disease Prevention and Health Promotion), Office of the Assistant SecretatT for Health, Washington, D.C. A. J. McMichael', M.D., M.B.B.S., Ph.D., Chairman and Senior Principal Research Scientist, CSIRO Division of lluman Nutrition, Adelaide, South Australia D. J, Moschandreas, Ph.D., Research Director, ITT Research Insti- tute, Chicago, Illinois David Muir, M.D., Director, Occupational liealih Program, Health Sciences Center, MdMaster University, ltamilton, Ontario, Cana- da Richard Pete, M.A,, M.Sc., I..C.R.F.o Regals Assessor of Medicine, Radcliffe Infirmary, University of Oxford, Oxlbrd, England, Unit- ed Kingdom Otto Raabe, M.D., Laboratory for Energy Related Health Rdsearoh, University of California, Davis, Davis, California James L. Repace, Chief of Techuical Services, Indoor "Air Quality Program, U.S. Environmental Protection Agency, Washington, D.C. M.A.lt. Russell, F.R.C.P., Addiction ltesearch Unit, Institute of Psychiatry, University of London, London, England, United King- dora Roy J. Shephard, M.D., Ph.D., Director, School of Pliysical and t|ealth Education, University of Toronto, Tvrouto, Canada Frank E. Speizer, M.D., Channing Laboratories, ltarvard Medical School, Boston, Massachusetts Jesse 1,. Steinfeld, M.D., President, Medical College of Georgia, Augusta, Georgia .. David N. Sundwall, M.D., Administrator, IIealth Resources'and Services Admlolstration~ Rockville, Maryland Gregory W. Traynor0 Staff Scientist, Lawrence Berkeley laboratory, Berkeley, California Dimitrios Trichopoulos, Director. Department of ltygieue and Epide- miology, School of Medicine, University of Athens, Athens, Greece Kenneth E. Warner, Ph.D., Professor, and Chairman, Department of Public Health Policy and Administrotion. School of Public Health, The University of Michigan, Ann Arbor, Michigau Ernst L. Wynder0 M.D., President, American Health Foundation, New York, New York James lq. Wyngaarden, M.D., Director, National Institutes of Health, Bethesda, Maryland Frank E. Young, M.D., Commissioner, Food and Drug Administra- tion, Rockville, Maryland The editors also acknowledge the contributions of the following staff members and others who assisted in the preparation of this Report. Erica W. Adams, Chief Copy Editor and Assistant Production Manager° Health apd Natural Resources Department, Sterling Software, Inc., Rockville, Maryland ',Richard H. Amacher, Director, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Maryland Margaret L. Anglin, Secretary, Office on Smoking and Health, Rockville, Maryland John L. llogrosky, Associate Director for Program Operations, Office on Smokll~g and.Health, Rockville, Maryland Charles A. lh'own, Programmer, Automation and Technical Services Department, Sterling Software, Inc., Rockville, Maryland' Clarice 1}.- Brown, Statistician, Office on Smoking and Health, Rockville, Maryland " Richard C. I|rubaker, Information Specialist, Health and Natural • Resources Department, Sterling Software, Inc., Rockville, Mary- land Catherine E. Burckhardt, Secretary, Office on Smoking and Health, Rockville, Maryland Joannn II, Crichton, Copy Editor, llealth a~td Natural Resources Departmeut, Sterling Software, Inc., Reckville, Maryland Stephanio D. DeVoe, Programmer, Automation and Technical Services D,:partment, Sterling S~Rware, Inc., Reckville, Maryland Danny A, Goodman, Information Specialist, lteaith and Natural Resources Department, Sterling Software, Inc., Rockville, Mary- 'land Patricia E. Healy, Technical Information Specialist, Office on Smoking and Health, Rockville, Maryland Terri L. Henry, Clerk-Typist,. Offica on Smoking and Health, Rockville, Maryland Timothy K. Henaley, Technical Publications. Writer, Officp on Smoking nnd Health, Rockville, Maryland Shirley K. Ilickman. Data Entry Operator, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Mary- land Robert S. llutchings, Associate Director for Information and Pro- gram Development, Office on Smoking and Health, RockviJle, Maryland Maureen lllar, Editorial Assistant, Office on Smoking and Health~ Rockville, Maryland Julie Km~, Graphic Artist, luformation Center Management De- parLmt:nt, Sterling Software, Inc., Rockviile, Maryland Ruth C. Palu,er, Secretary, Office ou Smoking and Health, Rockville, Maryland Jerom{; A. I'aulson, M.D., Medical Officer, Office on Smoking and tlealth, R~ckville, Maryland xvll