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Handbook on Smoking Laws & Regulations for Massachusetts Communities A~ ~ ~ ..,, Nonsmoking and Health William F. Weld, Governor David P. Forsberg, Secretary of Health and Human Services David H. Mulligan, Commissioner of Public Health Gregory N. Connolly, Di~ID, MPH, Director, Office for Nonsmoking and Health Revised August I991 TI2567-0536

Handbook on Smoking Laws & Regulations for Massachusetts Communities Commonwealth of Massachusetts Department of Public Health Office for Nonsmoking and Health 617-72%0732 Prepared by Martha C. Wood Assistant Director, Office for Nonsmoking and Health William F. Weld, Governor David P. Forsherg, Secretary of Health and Human Services David H. Mulligan, Commissioner of Public Health Gregory N. Connolly, D~[D, ~IPH, Director, Office for Nonsmoking and Health Revised August 1991 TI2567-0537

Table of Contents Introduction Why Local Tobacco Regulations/By-la~s are Necessary to Restrict Public Smoking Secondhand Smoke ............................................................. Cazdiovasoular Effects ........................................................... Respiratory Di~eas~ ............................................................. AHergi~s, HeadaChes, Irritation ...................................................... ]/xposu~ to Secondhand Smoke ..................................................... M~ to Protect the Public Health .................................................. Development of Indoor Air Policies Technical Considerations ......................................................... tO Retail Stoles ................................................................ 10 Restaurants ................................................................. lO Child Care Fagilities ........................................................... 11 Public Transportation ........................................................... I 1 Workplac¢ ................................................................. 1 Cost to Employers ............................................................. Hffeotiveness of Ventilation ........................................................ Health Care Facilities ........................................................... 1~ Preventing Access to Tobacco by Children Why Access Regulations Are Necessary ............................................... Adolescent Smoking Prevalence ....................................... : ............ Laws ..................................................................... Fr~ Distribution/Reduced Pric~ .................................................... Sales by Persons Under Age 18 .................................................... 15 Broken PacLs ................................................................15 Vending Machines ............................................................. 15 Advertising .................................................................16 Model Regulations Section I- Authority ........................................................ 19 Section II- Section III- Section IV- Section V- Sect/on VI- Section VII- Section VIII- S~ction iX- Section XIV- Definitions ....................................................... Prohibition on Smoking in Public Places ..................................... 20 Workplace ....................................................... Public Places/Workplaces En'forcement " ' Other Applicable Laws ~" Tobacco Sales to Minors Prohibited ........................................ 23 Prohibition of Advertising of Tobacco Products on Transportation Vehicles ............... 24 Severability ........................................................ 24 Effective Date ..................................................... 24 Appendices Legal Authority for Boards of Health to Restrict Smoking in Public Places .......................... 26 Current Massachus&ts Laws and Regulations Regarding Smoking ................................ 27 Noncriminal Disposition By-law ...................... : ............................. 36 Samples of Local Regulations Limiting Smoking in Private Workplace ............................. 39 Bibliography ................................................................49 T12567-0538

Introduction The Handbook on Smoking Laws and Regulations for Massachusetts Communki~ has been developed by the Massachusetts Department of Public Health in respomo to requite &ore local boards of health on how they can best address the smoking problem. This is a joint effog betweon this offico and the many boards of health that have work~l to curb smoking. We urge all boards to adopt rogulafions such as those contained in this handbook. Action at tho local Iovd is critical to tho overall effort to protect the health of the nonsmoker and limit access of tobacco products to minors. Cigarette smoking is the reading can,so of preventable death and disease in Massachusetts causing an estimated 11,000 deaths each year or 20 percent of all deaths in the state. Unless something is done to curb tobacco use, the epidemic of disease and death will continue far into the next century. Based on current smoking rates, of all the people alive in the state today more than 400,000 are expected to die prematurely from tobacco use. This is far more deaths than are expected to occur from alcohol, auto accidents, AIDS, and illicit drug use combined. Prevention of these tobacco-rdated deaths is one of the greatest public health challenges that we will face in our lifetime. Effective intetwentions exist to curb tobacco use but have not been uniformally applied at the state or local level. These include policies and programs that prevent youth teem smoking, help smokers to quit, and protect nonsmokers from the harmful effects of secondhand smoke. In combination, these interventions can establish social norms that discourage tobacco use and promote health. More than 70 communities have passed regulations protecting clean air in public places, restricting smoking in the pri;,,ate work-place, and preventing children from illegally purchasing tobacco products. Smoking in the workplace is of increasing concern because of the initial classification of secondhand smoke by the United States Environmental Protection Agency as a class A carcinogen (causing cancer). There are only six other compounds that have been classified in this category including benzene, vinyl chloride, and asbestos. It is our hope that all cities and towns will use this book to promote a healthier, smoke-tree environment. It is through a partnership of local and state action that lasting change can occur. Local action will set the stage for passage of new state policies that will protect the health of all residents. Gregory N. Connolly, DMD, MPH Director, Office for Nonsmoking and Health August, 1991 TI2567-0539

Why Local Tobacco Regulations/Bylaws/Ordinances are Necessary to Restrict Public Smoking Secondhand Smoke Secondhand smoke is a combination of sidestrsam smok~ produced by a lit cigarctm, cigar, or pipe and mainstream smoke exhaled by a smoker. About 80% of secondhand smoke is sidestream smoke. Tobacco smoke contains m~re than 4,000 toxic chemicals including tat, nicotine, cvxbon monoxide, and ammonia. Sixt~n are known to ¢anse cancer, Since side~troam smoke is created at a lower temperature than mainstream smoke, it contains higher concentrations of toxic chemicals. Cigarette filters do not effect sideslze~n smoke. The level of secondhand smoke in buildings is governed by the amount of smoking allowed and the amount of ventilation. The Environmental Protection Agency ~PA) and the National Institute for Occupational Safety and Health (NIOSH) recommend restricting smelting to separately ventilated areas dkecdy exhausted ~o the outside, or by entirely eliminating smoking in a building. Health Effects of Secondhand Smoke S~condhand smoke causes or aggravates many diseases including lung cancer and hear~ disease. Secondhand .smoke is the second leading cause of lung cancer, resulting in an estimated 5,000 deaths per yeas. A recent study e~timates that ll,000 additional Americans die each year from other forms of cancer caused by secondhand smoke, including cancers of the liver, cervix, nasal sinus, and blood (leukemia) and 30,000 nonsmokers die f~om hear~ disease caused by exposure to secondhand smoke. Secondhand smoke appears to be more efficient thaa direct smoking in producing disease per microgram dose of tar, This means that tbr the same tiny dose of tar, the nonsmoker may actually get sicker than the smoker who gets it by puffing on a cigarette. A possible reason t'or this is the different chemistry in sidestream and mainstream smoke. Another is the particles of secondhand smoke are smaller, allowing more of them to penetrate deeper into the small air sacs of the lung. Some of the tar deposited in the lungs gets into the blood and lymph systems, which circulate it to other parts of the body and allows it to remain longer in the body than tar from active smoking. Cancer Tobacco smoke contains 43 cancer-causing chemicals. The United States EPA states that secondhand smoke is a known cause of lung cancer. A recent study found that children who grow up in households where cigarettes are smoked are at increaseai risk for cancer as adults. The researchers concluded that household exposures of both parents smoking tbr 12Vz years during a person's childhood and adolescence doubles lung cancer risks. Tobacco smoke is the greatest indoor source of benzene, which is known to cause leukemia. Secondhand smoke accounts for about 5% of-the total benzene exposure nationwide according to the EPA. People who are exposed to secondhand smoke at work more than 50% of the time have shown significantly higher breath concentrations of benzene than those exposed less often. Polonium. another component of secondhand smoke, is also carcinogenic (cancer-causing). Other carcinogens tbtmd in secondhand smoke include 2-naphthalene, 4-aminobiphenyl, and N-nitrosamines. N-nitrosamines are found in quantities up to 100 times greater in sidestream smoke than mainstream smoke. Nonsmokers in an extremely smoky room tbr one hour can inhale as much N-nitrosamins as they would by smoking l0 to 15 cigarettes. TI2567-0540

Cardiovascular Effe~s Unlike the devdopment of c~mcer due to secondhand smoke, which in humans seems to be a long-term process, there are several hnmediate detrimental effects on the hem and blood vessel system. The transportmion of oxygen by red blood cells is hnmediately hampered by the carbon monoxide (CO) in secondhand smoke. CO is a colorless, odorless gas that comp~tes with oxygen for binding sites on hemoglobin in red blood cells, thus reducing the ability of blood to transpor~ oxygen. In lung and cardia~ patients, episodes of angina and acute shorme~s of broth can be provoked by secondhand smoke. Just one cigarette can increase the level of CO from an average of 2 ppm to 8 ppm in a 10 x 12 - foot room with the windows open. In people with narrowed coronary blood vessels, even lower -concentrations of CO can cause angina to develop earlier. There is also evidence that passive smoking makes blood platelets abnormally "sticky" and more likely to ag~egate and form clots. Increased platelet aggregation plays a role ~n heart attacks as well as in the development of atherosclerotie "plaques," the fatty deposits in coronary artery walls that often lead to hear~ attacks. Components of secondhand smoke may damage the inner walls of coronary arteries and initiate or accelerate development of these plaques. Respiratory Disease Another component of tobacco smoke is hydrogen cyanide which interferes with the action of the tiny cilia hairs in the lungs. It is also an extremely strong lung irritant and more potent than carbon monoxide in its abiIity to starve a person of oxygen. Active smoking is a major cause of approximately 85 % of chronic obstructive respiratory disease, but even low-dose secondhand smoke exposure can cause problems. People who are exposed to various occupational hazards, who suffered childhood respiratory illnesses, or whose airways are shrunken or hypersensitive are more susceptible to chronic respiratory disease caused by secondhand smoke than people without these conditions, Studies also indicate that people exposed to secondhand smoke as children are even more likely to have respiratory problems as adults. Persons with long-term secondhand smoke exposure have pulmonary function test results equal to those of light smokers. Chronic secondhand smoke exposure significantly reduces the small aii'ways' ability to function. One study shows 200 to 300 women die in.this country each year from emphysema and chronic bronchitis caused by secondhantt smoke. Secondhand smoke causes acute and chronic respiratory problems, including pneumonia and reduced lung development among young children. It also causes more frequent ear infections in them. Nine million Americans have asthma and 34 million have respiratory tracts that are sensitive to cigarette smoke. They must use public buildings, mass transit, and other public spaces. For them, tobacco smoke is one of the most.strip,us problems they face daily, contributing to this group's loss of 7 million days of work per year. Allergies, Headaches, Irritation Secondhand smoke is a common and aggravating factor in chronic sinusitis and post-nasal drip, allergies. eye irritation, coughing, and headaches. One reason for this may be the ammonia in secondhand smoke. Ammonia is a powerful eye and respiratory irritant. Some people do not realize that smoke is what causes 2

these problems, so they make no a~empr to avoid other peoplo's smoke. A Canadian s~dy found r~at ong-fiRh of those studied had a health condition aggravat~ by secondhand smoke. The American Medical Association estimates that as many as 34 million Americans are ~pecially sensitive m tobacco smoke. Chemical analysis of the smoke ~rom pipes, cigars, and cigaxett~ indicates tha~ cm:cinogens are found in similar levels in each. Experhnem~l studies have shown tha~ smoke condensat~ from pipes and cigars are equally, if not more, carcinogenic than those from cigarettes, according to the 1989 Surgeon General's repor~ on smoking. Exposure to Sere. ndhand Smoke The average person is indoors 80 to 90% of the time; thus it is essential to p'rotect the quality of indoor air. Where smoking is permitted, nonsmokers encounter secondhand smoke over an extended period of time and in significant doses. The EPA states that secondhand smoke represents one of the largest sources of indoor air pollution. It rapidly diffuses tkroughout a building and persists long after the smell of smoke disappeazs. As more than 28% of Massachusetts residents smoke, exposure to secondhand smoke is common in the state. Factors that determine the tevd of exposure to secondhand smoke include the size of the room, the number of smokers, and the amount of ventilation. Nonsmokers' exposure will also vary depending on the amount of time spent in enclosed places where smoking is allowed. The simple separation by space of persons in an enclosed environment may reduce but not eliminate the problem because tobacco smoke rapidly spreads throughout .the area. Air filters have been suggested as a method of cleansing indoor air of smoke, but currently there is no cost-effective filtration system. Air filters are easily overloaded by continual smoking, so the filters quickly become clogged and ineffective. Smoke particles are so tiny that they remain suspended in the air t'or a long time. The only way to remove smoke from a building is to increase the exchange of indoor air with outdoor air, When smoking is permitted, the number of air exchanges per hour must be greatly increased over the number required if smoking is prohibited. Of course, the energ-y costs of exchanging air are compounded in heated or air-conditioned buildings. Measures to Protect the Public Health Cities and towns have the responsibility and the authority to protect the public from exposure to indoor air pollutants. Since 1981 more than 70 Massachusetts communities have passed local regulations restricting smoking because of the health risks and nuisance created by it. Many communities have been reluctant to act because of the perception that people have a right to use a legal product publicly. This perception is not valid in light of the Surgeon General's 1986 finding that secondhand smoke causes disease among healthy nonsmokers. Based on this finding, cities and towns have the respo~sibility to protect the health of the nonsmoker by restricting smoking. Public attitudes have also shifted: the majority of the state's residents now support smoking restrictions. In the Department of Pubtic Health's (MDPH) 1986 Health Interview Survey, 67% of the respondents favored nonsmoking sections in restaurants and 21% favored a total ban on smoking in restaurants, The same survey found that 67% of the respondents favored smoking restrictions in the workplace. In some communities the initiative to restrict smoking came from citizens, while in others it began with the board of health. Boards of health have the statutory authority to promulgate smoking regulations. Good TI2567-0542

communication among the various municipal bodies is essential to the successful passage and enforcement of any regulation. Enforcement of smoking restrictions has not be~n a problem and, in the case of restaurants, has not affected the amount of business. In a 1987 MDPH survey of 106 restaurants in Massachusetts communities with smoking restrictions, 83% of the managezs reported the restrictions had no effect on business and 7 % felt they gained patrons because of the restrictions. Only 8% felt they had 1o2 business. The communities also found few problems in implementing the restrictions. Some restaurants have entirely prohibited smoking voluntarily and report reduced bum damage and cleaning costs. In summary, many Massachusetts communities have successfully passed local regulations that protect thv health of nonsmokers from the adverse health effects of secondhand smoke. Establish/rig a nommoking environment may also have an important side effect: helping smokers who are trying to quit. The findings of the Surgeon General and numerous scientific studies should provide incentive for other communiti~ to follow suit.

Some Toxic and Tumorigenic Agents in Secondhand Smoke Type of Compound Toxicity Vapor phase Carbon monoxide T Carbonyl sulfide T. Benzene C Fonnaldehyd~ C 3-Vinylpyridine SC Hydrogen cyanide T Hydrazine C Nitrogen oxides (NO,.) T N-Nitrosodimethylamine C N-Nitrosopyrtolidin~ C Particulate phase Tar C Nicotine T " Phenol TP Catechol CoC 0-Toluidine C 2-Naphtylamine C 4-Aminobiphenyl C BerLz(a)anthracene C Benzo(a)pyrene C Quinoline C - NNN (N-Nitrosonomicotine) C NNK (4-(methyinitros~unino)-(3-pyridyl)- 1-butanone C N-Nitrosodiethanolamine C Cadmium C Nickel C Polonium-210 C T = Toxic C = Carcinogenic (cancer causing) CoC = Cocarcinogenic SC = Suspected Carcinogenic 5 TI2567-0544

Srn s k986Prevalence 32% 34X 32% Age Group Male f77/1 Female Massachusetts Department of Public [Health 6 TI2567-O~z~