Tobacco Documents Online

PASSIVE SMOKING A~D T~ ~N~OCENT VIL~IM: A D~ILEMMA~O~ POLICY MA~E~S by John C. Topping, /Until recently involuntary exposure to cigarette smoke has been treated more as a ma~ter of social etiquette, than of public health. The nonsmokers' rights movement has been portrayed by tobacco interests as an assemblage of finicky busybodies in~en~ on imposing their values on smokers, lu the past year the passive smoking issue has taken on new dimensions as e~vidence has mounted ~ha~ invQluntary exposure to tobacco smoke may be one of the env~ronmengal sources of death. Recently through the courageous leadership of groups such as Mothers Against Drunk Driving we have become more conscious of the slaughter on our highways caused by alcohol abuse and have taken concrete steps ~o curb ~his abuse. Due ~o those efforts alcohol related deaths have dropped dramatically in recent years. Of the approximately ~wenty two thousand annual aLcoho~ related traffic fatalities in the U.S. about hal~ are drunk drivers themselves. Of the remaining eleven ~housand or so victims, according to the National Safety Council, at least half are clearly innocent ,ictims, passengers of other cars or pedestrians, with the remainder consisting mostly of passengers in the vehicles driven by persons i under ~he ~nfluence of alcohol. Efforts ~o curb drunk driving have undoubtedly saved lives of persons in each of ~hese cagegories, sparing the lives of potential drunk drivers, their willing or unwilling passengers and innocents who would have had the misfortune to come across these drivers on the highway. TI071 "1-2024

Our experience ~@ealiug with. drunk driving is instructive as we approac~/a source of death of equal or ~reaCer nm~n£tude, passive cancer death rate among nonsmokers from involuntary exposure Co tobacco smoke o£ about five thousand. These projections have gained acceptance in the public health community as indicated by an editorial in che~currenc ~ssue o£ the American Review of Respiratory Disease by Scott T. Neiss~ ~oDo'~ Associate Professor o£ ~ed£c£ne at Harvard ~edical School, Repace and Lowrey s lung cancer risk pro~ecCions appear consiscenc with the findings of a number of / epidemiological studies indicating elevated lung cancer risk from 4 • ' exposure to sidestream tobacco smoke. Th~s five thousand annual projection for lung cancer deaths alone from sides~ream tobacco smoke exceeds mos~ curren~ ~o~al annual cancer estimates for general~ population exposure outside ~he workplace ~rom all industrial r£sR from involuntary exposure ~o ~obacco appear ~o be ~he mos~ ££~Iy supported o£ ~he passive smoking risk projections, they m~y represent only ~he tip o~ ~he iceberg o~ ~he heat~tt damage ~rom such/ 6 exposure. Delecerious effects of maternal smoking during pregnancy on the developing fetus seem firmly established~ as reflected in the currently mandated health ~arnings on cigarette packages. One study, Gold, et. el., has reported a five-fold increase iu risk for brain tumors amonE children whose mothers continued co smoke during pregnancy.7 Two studies show differing results on the association between mothers who smoke~ and increased risk of leukemia among their ohildreno A study by Neutel and Buck found that the leukemia risk for these children nearly doubled over that for children whose mothers did not smoke# while an earlier study by Manniug and Carroll reported no such increased risk.8 In a recent article Sandler# eCoal_.___.~., report an increased risk of cervical cancer among women 9 whose fathers smoked. -2- 3-10711-2025

The mechanis~ms b~ich parental smoking produces elevated.risk of cancers other ~han lung cancer do uo~ seem clearly determined aud could include exposure to sides~ream tobacco smoke, transplacental passage Co the developing fetus of mainstream and aides,ream ¢obacco smoke inhaled by the mother, or smoking induced changes in the sperm of ~he father prior to concepcion or a combination of these £actors.lO If we are ¢o minimize cancer risks from involuntary exposure ~o ~obacco smoke, ~ur~her research by hea~h scientists on ~he specific mechanisms elevating such cancer risk would be desirable. Yet ~rom the viewpoint of policymakers an~ citizens a~ike ~he p~esen~ evidence, fragmentary though it is, seems sufficient co warran¢ s~roug steps to cut down involuntary exposure ~o cigarette smoke. One of the most perplexing aspects of the passive smoking problem is the link of childhood illness to parental smoking. Smoking parents are normally just as loving and concerned about ~heir children as nonsmoking parents. Most are undoubtealy oblivious ~o the mountain of health evidence showing that exposure to sidestream tobacco smoke increases risk of chlldhood illnesses. Several studies have linked maternal smoking to higher ratea for infants incurrin~ pneumonia and bronchitis during the first year of life. An Israeli study of 10,672 infants showed dramatic d~fferences in hospitalization rates for pneumonia and bronchitis during the first year of life between children of nonsmoking mothers and children of smoking mothers.~I Children of nonsmoking mothers averaged 9°5 hospitalizations per 100 children, wh£1e those whose mothers smoked more Chan twenty cigarettes a day averaged 31.7 hospitalizations per 100.12 Other epidemiological studies have linked paternal as well as maternal smoking ~o increased incidence of childhooa respiratory illness. A study of ~,071 children aged 5-14 in Western -3- T10711-2026

Pennsylvania shqwed-t.~t rates of chest i11ness greater than three days during the past year were 8,8 percent among children with no smoking parents; illness rates were 11.8 percent when one parent 13 smoked and 13.6 percent when two parents smoked. A study of 3,920 children aged 10-20 in France showed that parental smoking correlated with much higher rates of tonsillectomies and/or adenoidectomies, Twenty eight percent of children of nousmoking parents had such operations, compared with 42 percent of the children with a single smoking parent and 51 percent of the children with two parents who smoked.14 Parental smoking has also been linked with significantly increased rates of middle ear illness among pre-schoolers- Although the greater accessibility of data on family smoking habits and childhood or spousal health provides us considerably greater understanding of passive smoking in ~he home, there is evidence that tobacco smoke concentration and health risks may'be greater in the workplace. James L. Kepace, one of the pioneers with A.H. Lowrey in research on passive smoking, summarizes the flndings the two have made in a series of studies: .... the smoke pollution inhaled indirectly from cigarettes, pipes, and cigars indoors was not only chemically related to the smoke from factory c~imneys~ but routinely occurred at far higher levels indoors than did factory.smoke or automobile exhaust outdoors. [Our] controlled experiments and field studies showed that i6 buildings where tobacco is smoked, substantial air pollution burdens were inflicted upon nonsmokers, far in excess of those encountered in smoke-free indoor environment~, outdoors, or in vehicles on busy commuter highways. Daily exposure to ambient tobacco smoke, [we~ found, could cause air pollution levels corresponding to violation of the annual Na¢ional Ambient Air Quality Standard for To~al Suspended Particles for exposed office workers, at typical building occupancies~ and ventilation rates, and amounted to-the single most important source of exposure of the population to this harmful kind of air pollution. 16 -4- T!0711-2027

Tobacco particulate consists overwhelmingly of respirable small particles.17 ~coEnizing that particles of 10 microns or less are readily inhaled into the lungs where they cause respiratory dif~iculty~ EPA has proposed adoption of a heal~h s~andard keyed ~o 18 particles of i0 microns or less. Some health studies have indicated that passive smokin8 exposure o~ adults may significantly increase risks of heart attack° Garland e~. al~ found in a prospective study of 695 Southern California married women who had never smoked tha~ over a 10 year period nonsmoking wives of ~urren~ or ~ormer cigarette smokers had a higher total and age-adjusted death rate from ischemic heart disease than 19 women whose husbands never smoked. This is not particularly surprising as we know sidestream tobacco smoke includes substantial 20 quantities of carbon monoxide. EPA recently reaffirmed a National Ambient Air ~uality Standard of 9 parts per million, 8 hour average, of carbon monoxide not to be exceeded more than once a year. A significant factor fn this reaffirmatiou was evideuce that exercising ansina patients exposed to elevated levels of carb0u monoxide showed more rapi~ onset of angina pain. ~u oue study, Pimm e~oa___.~l, (1978) exposed nonsmoking adults to tobacco smoke in an exposure chamber and realized relatively coustaut levels of carbon monoxide of abou~ 2~ parts per million a~ove ~he am~ieu~ level~ concentrations three times EPA's 8 hour average carbon monoxide 22 standard for ambient air. Such levels are probably o~ten reached when smoking occurs in enclose~ environments with little ventilation such as many ~averns, restaurants, banque~ halls, closed 23 cars or taxicabs. Within a few minutes elevated carbon monoxide levels ~n the air which is breathed will be reflected in increased levels of blood carboxyhemoglobin. As blood carboxyhemoglobin levels rise, the blood's capacity to carry oxygen is diminished, thus increasin~ risk of heart attack or stroke. Approximately 8.7 million individuals are known ~o suffer from angina and related cardiovascular disease. These individuals can be presumed ~o be aE special risk from both mainstream and sidestream tobacco smoke. -5- TI,0711-2028

• oo About 3 per~ent.o.f_.~he populatiou, many acute asthmatics, . bronchitics or atopics, are allergic to ~obacco smoke. Such hypersensitive individuals report frequent nose and ~hroat irri~ation, wheezing, coughing, nausea ann sometimes persis~eu~ headaches fo~lowinE exposure to ~obacco smoke.2~ A much larger poruion of ~he nousmokin8 population appears ~o experience some of annoyance or distress a~ involun~a~ exposure ~o ~obacco s~ke. This is espec~ally ~nue o~ ~huse who have never smoked, abou~ ~¢ percen~ of ~he ~o~a~ U.S. population. ~n 1979~ eighty p~rcan~ o~ ~hosa who indicated ~o ~n~arviewers ~ha~ ~ever smoked~ reported ~haC ~ was "annoyin~ to be near a person who Despite the deep aversiou which many nonsmokers have long had at being forced to inhale others' tobacco smoke, until recently they have beeu ou the defensive. A social onus has existed on the nonsmoker who replies negatively to the sometimes proffered plea, "Do you mind if ~ light up?" Tobacco smoking has moved over three generations from an almost exclusively male ritual focuse~ around pipes and cigars and found geuerally at saloons, ~s and smokin~ parlors to a socially pervasive cigarette based addiction 27 involving all classes and both sexes. This mass marketing of tobacco has already claimed a fearful toll with the great bulk o~g--fIT~'e~sualties being smokers themselves. The health watchdog group~ Norldwatch, projects tha~ ~obacco use causes between ~wo m£11ion and two and a half million deaths each year across ~he world~ with abou~ three hundred seventy five t~ousand deaths in the U.$.28 ~eASa lineal descendent of Sir ~umphrey Gilbert~ fellow explorer half brother of Sir Walter Rale£gh~ ~ must ruefully concede thaC s I may have had more prescience than is generally ascribed to / lhlm by historians. Sir Walter Ralei8h is o£cen credited with ~07~ ~-202~

popularizing tob~cco.~n Che court of ~ueen Elizabeth. As a result of his intrigues in Che court he was consigned in lb03 to the Tower of London where he languished for 13 years before being released and two years later returned to the Tower, There under warranC of King James I he succumbed to the headsman's ax in 1618o ~'¥et such drastic measures would not seem in order today in our •ore libertarian society. Sur&eou General C. Everett Koop has articulated what is a laudable goal, "a smoke free society by the year 2000." Yet as our experience wi~h Prohibition has shown~ whatever the liabilities of a widely shared habit, legally coercive efforts to shppress it may prove counterproductive and breed disrespect for the law. ~f the Surgeon General's ~oal is interpreted as a society ~..~_n.~smoker9 are free ........ f~om invglu~tary inh~l~tio~.~.f.to~acco smoke, ~ha~ ~ould ..... be achievable. well before ~he year 2000. Such a policy, fully implemeuted,._w_?~d s~ve.~h~ l~e~.of thousands of nonsmokers annually. Yet for each nousmoker's life spared, ~t is virtually ce~n tha~ the lives of several smokers will be saved. Efforts to protect the lives of nonsmokers will necessarily ~nvolve severe restrictions or bans on workplace smoking, especially in enclosed environments.29 These restrictions ~ill themselves result in some curtailment of tobacco consumption-. Noreover, the willpower smokers develop to refrain from smoking when ~hey would imperil others may help them co kick ~he habit. A high percentage of smokers would like to do precisely that, but because of nicotine or other tobacco related dependency have not been successful. ~Significantly protective standards against involuntary alation of dangerous quantities of tobacco smoke are not likely often to be me~ by sequestration and ventilation in most buildings. - 7- TI0711-2030

~f we are ~o achievel.obacco smoke risk levels for nonsmokers no higher then those we ~olerate for industrial carcinogens, air exchange rates akin to those found in wind tunnels would often be 30 required. For economic and technical reasons such ventilaniou would not be feasible. Passive smoking in the home ~ not and should not be susceptible to government regulation, Family members share a concern for each other which should cause them to adopt more considerate behavior once theF have facts on ~he health risks of passive, smoki~. Following on the recent, salutary expansion of ~he health warning on cigarette packages should be added warnings ou theris~s to nonsmokers ~f involuntary exposure to tobacco smoke. Elimination of unwan~ tobacco pollution in the workplace and informing the public of the health risks attendant to passive smoking will strike at some powerful economic interests. While the stakes for the public health are enormous in this battle, it would be Pollyanaish to assume easy sledding. ~f the public is to ac~ intelligently to address this problem, the health science conunuuity must speak out clearly. This Workshop is an auspicious beginning. *A graduate of Dartmouth College and Yale Law School, the author has served since September 1983 as Staff Director of the Office of Air and Radiation of the U.S, Environmental Protection Agency which he is leaving on January 31, ~98o to reenter private law practice. This presentation attempts to survey the health evidence on passive smoking and relate it to the knowledge in the air pollution.control community of health damage caused by pollutants. Any policy preferences are those of the author as EPA has deferred to the Surgeon General as chief administration policymaker on issues Of smoking and heal~h. As an employer, however, EPA has begun, due to the initiative of its own employees, to take tangible steps to reduce health risks from passive smoking in the SPA workplace. In its Boston regional office smoking is banned except in two restrooms, in the Philadelphia region~l office smoking is restricted to a few vending rooms, and in the ~eattle region job announcements notify applicants that smoking is prohibited. EPA Times, Vol. 2 No. I~, June ~985, at I. -8- T10711-2031

i Charles ~rle~, National Safety Council~ January 13, 1986 Telephone Convet~satio~ ~th Author. Total U.8. traffic fell from 51,091 in 1980 to 44,241 in 1984 despite a large increase in vehicle m~les traveled. During chat time alcohol related fatalities dropped from about 28,000 per year ~o 23,500. Department of Transportation, National Highway Traffic Safe~y Administration, Alcohol Involvemen~ in Fatal Accidents~ 1980-1984, Section 3, June 198~, 2 James L. Repace and Alfred H. Lowrey, "A ~uantitacive Estimate of Nonsmokers' Lung Cancer Kisk from Passive Smoking, "Environment ~nternation91, Vol. 11, [985. 3 Sco~ T. Weiss, MOB., "Passive Smokir~ and Lun~ Cancer: Wha~ is the Risk?", ~merican Review of ~espiraCor~ Diseage~ January 198b. ~ See TakashiHirayama, "Non-Smoking Wives of Heavy Smokers Have A Higher ~isk of Lung Cancer: A Study From Japan," ~riClsh Medical Journal, January 17~ 1981; D. Trichopoulas at el., "Lung Cancer and Passive Smoking," International Journal of Cancer~ Vol. 27~ 1981; and Pelayo Coffee, "Passive Smoking and Lung Cancer", Lancet, September I0~ 1983. Significant correlations ~etween husbands-' smoking and wives lung cancer rates were not found in Lawrence Garfinkel, "Time trends in lung cancer mortality among nonsmokers and a note on passive smoking," Journal of the National Cancer ~.nnstitute, 66~ 1981. Ye~ the Garfinkel data when adjusted for possible workplace exposure of working wives seem consistent with other passive smoking o~servations. James L. Kepace~ "Consistency of research date on passive smoking and lung cancer~" ~ncet 2~ 506~ 198~. A recently published study by Garfin~el an~ two colleagues showed marke~ly higher lung cancer rates ~or nonsmoking women whose husbands smoked at home than for women married Co nonsmokers. Lawrence G~r~n~el~ Oscar Auerbach, and Lou Jouberc~ "~vo~untary Smoking and Lung Cancer: A Cas~-Con~rol" ~tudy," Journal of the National Cancer ~nsC~Cu~, Vol. 75, No. 3, September-1985. 5An EPA study of cancer ~ncidence from 15 of the leading industrial carcinogens yielded estimates of 1,300-~,700 deaths annually among the general US population. See V~vian Thomson, Alan Jones, Elaine Haimisegger and Bern Steigerwald~ "The Air Toxies Problem in the US: AnA nalysis of Cancer Risks Posed by Selected Air Pollutants. Journal of the ~r Pollu~ion Control Asso¢iati~, Vol. 35, No. 5, May 1985. 6 Peter FortE, Physics Department, Emory University has projected ~hat passive smoking exposure of nonsmokers is responsible for between I0,000 and 50~000 deaths annually. Fong, "The Hazard of C~garet~e Smoke co Nonsmokers," J. Biolo Ph~.s., Vol. ~0, 1982. -9- T1,07"1"i-2032

7 E. Gold, L. Gqrdis,._J.. Touascia and M. Szklo, "Risk Factors for Brain Tumors in'Children," A~erican Journal of Epidemiology, 109: 309-319, 1979. 8 M. D. Manning and B. E. Carroll, "Some EpidemioloEic Aspects of Leukemia in Children," Journal of the National Cancer Institute, 19: 1087-1094, 1957. 9 Dale P. Sandier, MPH, Ph,D,, Richard D. Eversou, MD, Allen J. Wilcox, MD, Ph.D., and James P. ~rowder, MD, "Cancer Risk in Adulthood from Early Life Exposure to Parents' Smoking," American Journal of Public Heal~, Vol. 75, No. ~, May 198~. 10 For a discussion of these mechanisms see Sandler et. el., Cancer Risk in Adulthood from Early Life Exposure ~o Parents' SmOking," a~ ~91. 11S. Harlap and AoM. Oavies, "Infan~ Admissions to Hospital and Maternal Smoking" Lancen I (~857): 529-532, ~arch 12 ~arlap and Davies, 13 Marc B. Schenker, Jonathan M. Samet and Frank E. Speizer, '*Risk Factors for Childhood Respiratory Disease: ~he ~£fect of ~ost Factors and Home Environmental Exposures,'* American Review of Respiratory Diseas@, 128(6): 1038-1043, December 1983. 14 G. Said, J. Zalokar, J. Lellouch, and E. ~a~ois, "Parental Smoking Rela~ed to Adenoidectomy and Tonsillectomy in Children,*' Journal of Epidemiolo~7 and Communiiy Health 32(2), 9~-I01, June 1978. 15 M. 1versen, L. ~irch, G.R. bundquist and O. Elbrand, "Middle Ear Effusion in Children and the ~ndoor Environment: An Epidemiological Study, Archives of Environmental Heslth, Vol. 40, No. 2 March/April 1985. James L. Eepace, "Risk of Passive Smoking" in To ~reaChe ~reely:. Risk~. Consent and Air, Mary Gibson, Ed., Rowman & Allanheld, Tatowa~ N.J., ~985,~a~ 7. '" 17 For a de~ai~ed discussion of tobacco particulate see James L. Repace and Alred H. Lowrey, "Indoor Air Pollution, Tobacco Smoke, and Public Heal~h," Science, Vol. 208, 464-472, 2 May 1980. - I0- T10711-2033

18 40 CFR, Parr 50, 53, and 58, FR 1984, 10408, March 20, 1984. 19 Cedric Garland, Elizabeth Barrett-Connor, Lucina S~arez, Michael H. Criqui and Deborah L, Wingard, "Effects of Passive ~moking on ~schemic Heart Disease Mortality of Nonsmokers: A Prospec¢ive Study,"American Journal of Epidemiology, Vol. 121, No. 5, 645-650, 1985. 20 U.S. Surgeon General, The Health Consequences of Smoking: Chronic Obstructive Lung Disease, U.S. Departmeu~ of Health and Human Services, 1984 at 368. 21 40 CFE, Pare 50, FR 1985 37484, SepC. 14, 1985. 22,p.E. Pimm, F. Silverman, and E.J. Shephard, "Physiological Effects of Acute Passive Exposure to CisareCte Smoke," Archives of Environmental Heal~______~h, Vol. 33, No. 4, 201-213, July-Augus~ 1978. 23 U.S. Surgeon General, The Health Consequences of Smoking: Chronic Obstructive Lun~ Disease. 24 Eepace, "~isks of Pass'ire Smoking," 1985 at 6. 25 U.S. Surgeon General~ The Health Consequences of Smoking: Chronic Obstructive Lung Disease. 26 Repace, Risks of Passive Smoking, 1985 at 5-6. 27 For a discussion of the history of tobacco smoking in the U.S. see Frederic Speer, "Tobacco and the Nonsmoker: A Study of Subjective Symptoms," Archives of Environmental Health, 16, 1968. An ex~enslve exploration of the spread of ~obac¢o smokin8 Eo ~he developing countries can be'found in William ~. Chandler, Banishing Tobacco, Worldwa~ch, January 1986. 28 Chandler, Banishing Tobacco, 1986 ac 12 and 13. - II - T!0711-2034

29 Such severe r~sCri~ons would normally be unnecessary for most outdoor occupations, e.g. agricult~re~ couscructiou, etc. where smokin8 limitations would be more related to commousensical measures to avoid fire or explosion. Private offices with natural ventilation, i.e. windows tha~ open readily, could achieve rapid evaeua~iou of ha~nfu~ tobacco smoke. Provided tha~ smokers consistently used such natural ventilation, it migh~ be possible to permit smoking in such naturally ventilated private offices or designated smoking rooms withou~ exposing nonsmoking workers to significant heal~h risk. Such aocommodation to smokers would involve some modest additional energy expenditure by employers. 30 See James L. Repace and Alfred H. Lowrey~ An indoor air quali~y standard for ambient ~o~acco smoke based on carcinosenic risk," Hew York S~a~e Journal of Medicine, Volo 85, July 1985. The authors calculate ~hat ventilation ~o achieve an acceptable risk from passive smoking would require ~28,000 per smoker~ exclusive of fan operating costs. Repace and Lowrey~ 382. - 12- T10711-2035