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I I 21 I I N I N I THE HEALTH CONSEQiTENCES OF INVOLUNTARY SMOIiING I a report of the Surgeon General 1986 PREPUBLICATION EDITION This copy is issued as a prepublication edilion containing no subject index. A tinal edition wilhh index will be available approximately eight weeks from dale of release. : ;#i U.S. GEPARTMENT OE HEALTH AND HUMAN SERVICES PubNt Heelth Senke i Cenlers /a Oisease Caw+lrol Cenlei /or Mba111i Prorerolion.nd Edueatlon •_ v rot:r...- e.....~i......w Il..in. - - - _ --.. - a•.(46 Rock.lUe, Marylarid 2057

-1, 1 M r 12 -. __M -M -.W M FOREWORD The data reviewed in 17 previous U.S. Public Ilealth Service reports on the health consequences of smoking have conclusively established cigarette smokinQ ns the largest single preventable cause of premature death and disability in the United States. The question whether tobacco smoke is harmful to smokers was answered more than 20 years ago. As a result, many scientists began to question whether the low levels of exposure to environmental tobacco smoke (El'S) received by nonsmokers could also be harmful. The current Iteport, The Ilealth 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 term "involuntary smoking" denotes that for many nonsmokers, exposure to ETS is the result of an unavoidable consequence of being in proximity to smokers. It is the first Report in the health consequences of smokh+g scries to establish a health risk due to tobacco smoke exposure fvr individuals other than the smoker, and represents the work of nwre than 60 distinguished physicians and scientists, both in this country and abroad. After careful examination of the available evidence, the following overall conclusions can lxr reached: 1. Involuntary smoking is a cause of disease, including lung cancer, in healthy nonsinokers.. 2. The children of parents who smoke, compared with the children of nonsmoking pnrents, have an increased frequency of respiratory inlections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the lung matu res: 3. Simple separation of snwkers and nonsmokers within the same air space may reduce, but does not eliminate, exposure of nonsmokers to envirommental tobacco smoke. Exposure to environmental tobacco smoke occurs at home, at the worksite, in public, and in othcr places where smoking is perrniited.

I r I U I I . -M 0 .U The quality of the indoor environment nnust be a concern of all who control and occupy that environment. Protection ol individuals from exposure to environmental tobacco smoke is therefore a responsibili- ty shared by all: • As parents and adults we must protect the health of our children by not exposing them to environmental tobacco smoke. %, • 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 others. • For nonsmokers, it is their responsibility to provide a support- ive environment for smokers who are attempting to stop. Actions taken by individuals, employers, and employee organiza- tions reflect the growing concern for protecting nonsmokers. The number of laws and regulations enacted at the national, State, and local level governing smoking in public has increased substantially over the past 10 years, and surveys conducted by numerous organizations show strong public support for these actions among both smokers and nonsmokers. As a Nation, we have made substantial progress in addressing the enormous toll inflicted by active smoking. lalorts to improve and protect individual health must not only be cuntinued but strength- ened: On the basis of the evidence presented in this Report, it is clear that actions to protect nonsmokers from Cl'S exposure not only are warranted but are essential to protect public health. _ Robert E. Wiiidom, M.D. Assist:mt Secret.ary for llealth

r a W 1'REFACE This, the 1986 Report of Uie Surgeon General, is the U.S. Public Health Service's 18th in the health consequences of smoking series and the 5th issued during my tenure as Surgeon General. Previous Reports have documented the tremendous health burden to society front 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 overwhelrninR-totaling more than 50,000 studies from dozens of cultures. Smoking is now known to be causally related a 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 obstructive lung disease. It is estimated that smoking is responsible for well over 300,000 deaths annually in the United States, representing approximately 15 percent of all mortality. Thirty years ago, however, the scientific evidence linking smoking with early death and disubilit:v was more limited. By 1964. the year the Advisory Committee to the Surgeon General issued the first rehos-t un smoking and health, a substantial body of evidence had accumulated upon which a judgment could be made that smoking wrts 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 carcinogenicity of tobacco smoke, and the specific disease risks resulting from exposure to this ngent. This Report is the first issued since 1964 that identifies a chronic disease risk resulting from exposure to tobacco smoke for individuals other than smokers. lt is now clear that disease risk due to the inhalation of tobacco smoke is not limited to the individual who is smoking, but can extend to those who inhale tobacco smoke emitted into the air. This Report represents a detailed review of the health effects resulting from nonsmoker exposure to environmental tobacco smoke (ETS). E`I5 is the combination of smoke emitted from a burning tobacco product between puffs (sidestream smoke) and the smoke exhaled by Ute smoker. The 1986 Report, The Health Consequences of Involuntary Smoking, is a critical review of all the available scientific evidence pertaining to the health effects of ETS exposure on nonsmokers.'!`he term "involuntary smoking" is used to

 _r  _ar . _W M 0 I I I 1 -I I I I N note that such exposures often occur as an unavoidable consequence of being in close proximity to smokers. Lung Cancer and Environmental Tobacco Smoke The appropriate framework for an examination of Elie lung cancer risk from involuntary smoking is lhat of a low-dose exposure to a known human carcinogen. Over 30 years of research have conclu- sively established cigarette smoke as a carcinogen. This Report presents evidence thal the clrenrical comtrvsition of sidestream smoke is qualitatively similar to the mainstream smoke inhaled by the active smoker, and that both mainstream and sidestrearn smoke act as carcinogens in bioassay systems. Uata related to environmen- tal 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 Iuirg cancer risk; epidemiological studies of populations exposed to CI'S have documented an increased risk for lung cancer in those nonsmokers with increased exposure. It is rare to have such detailed exposure data or hunian epidemio- logic studies on disease occurrence when atterupling to evaluate the risk of low-dose exposure to an agent with established toxicity at higher levels of exposure. The relative abunilance of data reviewed in this Report, their cohesiveness, and their biologic plausibility allow a judgment that irivoluntary smoking can cause lung cancer in nonsmokers. Although the number of lung cnncers due to involun- tary smoking is smaller tlran that due to active smoking, it still represents a number sufficiently large to geuerate substantial public health concern. It is certain that a substantial proportion of Elie lung cancers that occur in nonsmokers are due to Cl'S exposure; however„ more complete data on Elie dose and vnriability of smoke exposure in Elie nonsmoking l1 S. population will be needed before a quantitalive 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 pneurnonia when compared with infants of nonsmoking parents. There is a relationship between parental smoking and an increased frequency of respiratory synrp- toms in children. A slower rate of growth in lung function has been observed in children of smoking p:rrents. In many studies, if both \

0 N N N N N parents smoke, a stronger relationship exists tisan if only one parent smokes. What future respiratory burden these findinga may represent for these children later in life is not known. As a former pediatric surgeon, I strongly urge parents to refrain from smoking in the presence of children as a tneans of prolecting not only their children's current health status but also Urcir own. Diseases Other Than Lung Cancer Several studies have provided data on the relationship between CI'S and cancers other tlian lung cancer and on ETS exposure and cardiovascular disease. I lowever, further research in these areas will be required to determine whether an nssociation exists between CI'S exposure and an increased risk of developing these diseases. Policies Restricting Smoking In Public Places The growth in our understnnding of the disense risk associated with involuntary smoking has been accompanied by a change in tlre social acceptability of smoking and by a growing body of legislation,, regulation, and voluntary action that addresses where smoking may occur in public. Forty States and the District of Columbia now have some form of legislation controiling or restricting smoking in various public settings. Some Strites limit snroking to only a few designated areas; however, States are increasingly developing and implement- ing comprehensive legislation that restricts smoking in many public settings, including the worki)lace. Nine States have restrictions that cover smoking not only by public employees but also by employees in the private sector. No systematic evaluation of the effects these measures may have on smoking 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 organWations, government ai;encies, nnd even the tobacco industry have documented that an overwhelming majority of both smokers and nonsmokers support restricting smoking in public. Public Health Policy and Involuntary Smoking The 1986 SSurgeon General's fteport on the llealth Consequences of Involuntary Smoking clearly documents that nonsmokers are placed at increased risk for developing disease as the result of exposure to environmental tobacco smoke. Critics often express thit more research is required, that certain studies are f]awed, 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; measures 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 remedial 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 or smokers and nonsmokers in the same room or in different rooms that share the same ventilation system may reduce ETS exposure but will not eliminate exposure. The responsibility to protect the safety of the indoor environment is shared by all who occupy or control that environment. Changes in smoking policies regarding the workplace and other environments necessitated by the data presented in this Report 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 groupss affected. ln addition, changes are often more effective when support and assistance is provided for the smoker who wants to quit. Cigarette smoking is an addictive behavior, and the individual smoker must decide whether or not to continue that behavior; however, it is evident from 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 expose nonsmokers to the potential harmful effects of tobacco smoke. C. Everett Koop, M.D. Surgeon Ceneral

1 TABLE OT CONTENTS Foreword .............................................................. vii Preface .......................................,.......................... ix Acknowledgments.................................................. . xiii Qlntroduction , Ov erview, and Summary and Conclusions ........................................................ 1 2. Health Effects of Environmental Tobacco Smoke Ex- posure ............................................................. 17 3. Environmental Tobacco Smoke Chemistry and Expo- sures of Nonsmokers ........................................ 119 4. Ueposition and Absorption of Tobacco Smoke Constit- uents ....:........................................................ 175 5. Toxicity, Acute Irritant Effects, and Corcinogenicity of Environmental Tobacco Smoke ....................... 223 6. Policies Restricting Smoking in Public Places and the Workplace ....................................................... 259

1 I I I ~ f CHAPTER i a I INTRODUCTION, OVERVIEW, I AND SUMMARY AND CONCLUSIONS

I I CONTENTS lntroduction Development and Organization of the 1986 Report p Overview Environmental Tobacco Smoke Constitutents Extent of Exposure Lung Cancer . Respiratory Disease Cardiovascular Disease Irritation Determinants of Exposure Policies Restricting Smoking Summary and Conclusions of the 1986 Report Ileallh Effects of Environmental Tobacco Smoke. Exposure Environmental Tobacco Smoke Chemistry and Exposures of Nonsmokers Deposition and Absorption of Tobacco Smoke Constit- uents Toxicity, Acute Irritaiit L•'ffects, and Carcinogenicity of Environmental! Tobacco Smoke Policies Restricting Smoking in Public Places and the Workplace