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DISCUSSION PAPERS are reports of work in progress in the fields of smoking behavior, policy, and disease epidemiology. The papers have not been published and have received limited review. The goall of the Discussion Paper Series is to provide investigators with an avenue for discussion of work prior to publication. TO PROTECT THE AUTHORS' FUTURE PUBLICATION INTERESTS, REPRODUCTION, QUOTATION, OR CITATION OF THIS DISCUSSION PAPER IS NOT PERMITTED~WITHOUT PER."IISSION OF THE AUTHOR. The views expressed in this paper are those of the authors and do not necessarily reflect those of the Institute for the Study of Smoking Behavior an&Policy or Harvard University. Requests or inquiries shoi..'dSe directed to: Matthew Myers,, Esquire Asbill, Junkin, Myers & 3-_:__one, Chartered 1607 New Hampshire Ave^,-~e , ... «. Fourth Floor Washington, D.C. 2~1,D09 r~c i Myers

NOT FOR QUOTATION OR CITATION WITHOUT PERMISSION OF THE AUTHOR THE POLICY IMPLICATIONS OF INVOLUNTARY SMOKING AS A PUBLIC HEALTH RISK Matthew L. Myers, Esq. Susan L. Arnold Asbill, Junkin, Myers & Buffone ._.:te for the Study of Smoking 3ehavior and Poliicv : .',nnedy School of Goverr^ent .._irvard i:rniversit•,: 'onn F. i:ennedv Street aTbridse, HA 02138' h1~1 ~`~5-~~806 May 1987 S-87-12

THE POLICY IMPLICATIONS OF INVOLUNTARY SMOKING AS A PUBLIC HEALTH RISK i Table of Contents Page Int'roduction ................................................1 I. The Findings of the National Research Council of the National Academy of Sciences and the Surgeon General of the Public Health Service ...............................................5 II. Policy Implications of the Findings of the Reports of the National Research Council and The Surgeon~ General ...................................... 9 A. Involuntary Smo;ang in the Home ........................ 9 B. Children and1nvoluntary Smoldng Outside The Home .......................................12 C. Involuntary Smoia~ng in Public Places .................... 16 D. Involuntary Smoang in Public Conveyances ................ 26 E. Involuntary Smoid~ng in the Workplace ................... 34 Conclusion ................................................ 50

INTRODUCTION - On November 13, 1986 the National Research Council of the National Academy of Sciences issued the results of its year-long study entitled Environmental Tobacco Smoke: Measuring Exposure and Assessing Health Effects. On December 16, 1986 the Surgeon General of the Public Health Service issued his annual raport on smoking and health. These reports are devoted to an examination and evaluation of the health effects of involuntary smoking. Both reports conclude that involuntary smoking can and does cause serious disease, including lung cancer, serious acute effects in otherwise healthy adults and severe respiratory problems in young children and infants. Together, the Reports of the National Research Council and the Surgeon General may well have an impact on the attitudes and health of our nation as substantial and as important as the 1964 Surgeon General's Report. Like the landmark 1964 Report of the Advisory Committee to the Surgeon General of the Public Health Service, these two reports represent the development of a firm consensus on the part of the nation's leading scientists that involuntary smoking is a proven hazard affecting the health, safety and comfort of millions of Americans. The finding that involuntary smoking poses a hazard to nonsmokers re-focuses the issue away from a debate over conflicting rights about whether smokers or nonsmokers are more inconvenienced and more irritated by the other's behavior. These reports mean that the issues posed by tobacco smoke exposure are likely to be examined in the context of questions of health and safety, including: When, if ever, should smokers be able to smoke in a location which jeopardizes the health of those who do not smoke? When, if ever, should the health of nonsmokers be balanced against the preference of smokers about when and where they smoke? What responsibility do employers, store owners and custodians of public buildino have to provide those who work or visit the buildings under their control with an environment which does not jeopardize their health? What is the impact of the fact that tobecco is voluntarily brought into that environment and that the

tobacco smoke could be eliminated without the use or introduction of expensive or new technology? The findings raise policy questions distinct from those posed by the 1964 Report. First, while the tobacco industry contends that a smoker can freely choose whether to smoke, a fact disputed by evidence of the addictive nature of cibrettes, involuntary smoking does not involve free choice for nonsmokers. Infants and young children have little control over their environment and are the least able to avoid involuntary smoking. Adults, too, on a daily basis find themselves in locations where they are unable to avoid breathing tobacco smoke in the air. Millions of adults work in smoke-filled environments and have little control over the air they breathe. Many public buildings have no restrictions on smoking and many public places, such as stores and restaurants, expose adults and children to involuntary smoking. Thus, the risk to nonsmokers from involuntary smoking is brought about by the actions of individuals other than themselves, and the resulted1:njury is not self-inflicted. The issue is not a matter of common courtesy or of choice, but rather a matter of protection against a documented health ha zar d. Second, while the estimat'ed' number of people who die each year from involuntary smoking is less than the number who die from their own smoking, the number of people ex,oosed~ to involuntary smoking is far greater. While an estimated fifty-five million Americans smoke, every person in the United States is exposed to tobacco smoke in the air, the only difference being how frequently and in what concentrations. This fact is significant in light of the lack of evidence that there is a threshhold~ below which exposure to tobacco smoke iu not hazardous. Third, different indivie,'uais are exposed to different levels of risk from tobacco smoke in the air due to a•wide variety of factors. For children, whose stage of physical development makes them especially sensitive to involuntary smoking, the level of risk depends largely on whether their parents and/or other caretakers smoke. For adults, the

-- - _ _--,~------~ 3 level of risk depends on whether their spouse smokes, where they work, whether their co- workers smoke, whether the ventilation in their work setting is adequate, whether they work in an environment where they are exposed to other substances which interact with tobacco and whether they live in a community which has acted to protect nonsmokers. For persons young or old with pre-existing respiratory or pulmonary problems, exposure to tobacco smoke may pose a more immediate health risk. The distinctions between smoking and~involuntary smoking affect the consideration of what steps should be taken to protect the public and who should bear the responsibility for the injuries which can result. Efforts to address the problems caused by the direct health hazards of cigarette smoking have been focused largely on educat~ing and assisting smokers and potential smokers not to start and/or to quit in order to protect their own health. Despite the recent spate of product liability suits by smokers and their families, the Courts have played no significant role with regard to the injuries suffered by smokers. With the exception of those state laws which restrict the sale of cigarettes to minors and Federal efforts designed to increase public awareness of the health~ hazards of smoking, the legislative branches of government have done little to protect smokers against the risks of their own smoking. In, contrast, the response to involuntary smoking is likely to be very different because the risks from involuntary smoking result from, the actions of others. In addition, the exposure often occurs in settings over which nonsmokers have little control. These factors aiter the public policy issues and the mechanisms for addressino them. These issues include: o What level of ri-3k to nonsmokers should be tolerated? Should the policy o~~l be the total elimination of exposure to tobacco smoke for those who do not' smoke? Is i't 3ufficient to eliminate exposure for those for whom the exposure is the 7reatest or who are at special risk or should it be eliminated en ti rely? o How much exposure is tolerable and under what conditions? 0 What should be done to protect infants and young children in the home?

o What can and should be done to protect children when they are in the care of institutions, such as daycare centers and schools? o When should government intervene to protect the health of the nonsmoker and when should the resolution of this issue be left to the private sector? o Who bears the burden of protecting the nonsmoker? In the home? In public buildings? In the workplace? ` o What role should existing regulatory mechanisms, such as OSHA play, and at what level of government? Are new approaches and new laws needed? o Who should be legally responsible for injuries suffered by nonsmokers from involuntary smoking? o What role should the courts take in apportioning responsibility and liability for injuries resulting from involuntary smoking? These are important questions which policy makers need to carefully consider. Government leaders, private sector empleyers, work supervisors, store owners, smo;ano parents and~ any individual who smokes in the presence of nonsmokers all have some deoree of responsibility.

5 I. THE FINDINGS OF THE NATIONAL RESEARCH COUNCIL AND THE SURGEON GENERAL After examining the available evidence, the National Research Council's Com mittee on Passive Smoking and the Surgeon General concluded: 1. Involuntary smoking is a cause of disease, including lung cancer, in otherwise healthy nonsmokers. A, 2. Infants and children exposed to tobacco smoke in the home have an increased incidence of serious respiratory infections such as bronchitis and pneumonia in early childhood, and smaller rates of increase in lung funct'ion as the lung m atures. 3. Healthy nonsmokers exposed to tobacco smoke in the air experience acute physical reactions including eye, nose and throat irritation. 4. _ The simple separation of smokers and nonsmokers in the same air space does not eliminate the exposure of nonsmokers to the harmful constituents found in airborne tobacco smoke. Preliminary studies have identified other risks to nonsmokers, including a reduction in the lung function of healthy adult nonsmokers, 1[ a higher risk for heart disease and an increased incidence of death from heart attack in individuals with pre- e:dstinD heart disease married to smokers, 2/ and the exacerbation of symptoms in individuals with, pre-existing lung disease or who are sensitive to tobacco smoke. 3/' The two Reports draw a careful distinction between those areas in which there is sufficient scientific evidence to conclude that involuntary smoijng is a proven health hazard and those areas in which more research is needed. For example, while the Reports find the evidence sufficient to conclude that involuntary smoking increases the risk of lung cancer in nonsmokers, they also conclude that additional research is needed before the same can be saio' for the relationship between involuntary smoking and cardiovascular disease, cancers other than lung cancer, and decreases in lung function in, otherwise healthy adults. The fact that the two Reports cautiously emphasize the need for more research in certain areas heightens the significance of their conclusions in those areas where they find the scientific evidence sufficient to draw meaningful scientific conclusions.

6 A. INVOLUNTARY SMOKING AND LUNG CANCER The NRC and the Surgeon General'concluded that involuntary smoking increases the risk for lung cancer in nonsmokers. The NRC report estimates that the increased risk of lung cancer for involuntary smokers ranges from 14 to 6A. 4/ The NRC risk range is based on a review of thirteen different studies on involuntary smoking and lung cancer conducted internationally and in the United States. Considering the worldwide data as a whole, the NRC estimates an average 34% higher risk of lung cancer for nonsmokers regularly exposed to tobacco smoke. 5/ Using only the data from studies conducted in the United States, the NRC estimates the relative increased risk of lung cancer to be 14%, 6/'accounting for approximately 2400 lung cancer deaths among nonsmokers in 1985. 7/ Based upon the NRC's figures, with the exception of asbestos, involuntary smoking causes more deaths than all of the other airborne pollutants regulated'by the Environmental Protection Agency combined. 8/ Although the majority of the studies on involuntary smoking and lung cancer use wives of smoking husbands as subjects, and have measured their exposure in the home, the Surgeon General's report states that there is no reason to believe that the increased risk of lung cancer is limited to exposure in the home. In fact, in, the United States nonsmokers often may be exposed to tobacco smoke for longer periods of time in the workplace. The finding that regular exposure to tobacco smoke increases the nonsmoker's risk for lung cancer is applicable to any enclosed environment, although the relative risks may vary depending on factors such as ventilation rates, the number of ~ smokers, the proximity of smokers, and similar considerations. ~ ~ G'1 a ~ B. INVOLUNTARY S`101{L*1G IN CHILDREN Q~ Both reports found that exposure to tobacco smoke is associated with a variety of ~ adverse health impacts in infants and children. The Chairman of the NRC Committee

. -. ~ ~.~ ~~~ ... __. . . _. . . . . . _. . - . . ~ - - . 7 stated that studies of children exposed to smoke at home are "remarkably consistent" in showing that such exposure is "clearly harm ful" to children of smoking parents. 9/ The Surgeon General's report reaches the same conclusion. 10/ The NRC and Surgeon General's Reports review the results of more than 25 studies comparing children of smoking parents with children of rionsmoking parents. The studies measure the effects of tobacco smoke exposure on respiratory symptoms, pulmonary function, and~ respiratory tract illness. 111 The data indicate that children of smoking parents develop lower respiratory tract illnesses such as bronchitis and~ pneumonia up to twice as often in the first year of life as children with nonsmoking parents. 12/ Respiratory symptoms, such as cough, sputum, and wheezing, occur in children exposed to tobacco smoke in a ratio from 1.2 to 1.8 compared to children of nonsmokers. 13/ Decreases in lung function (F£V) in children of smolang parents range from zero to 0.5% per year, a small effect' but possibly significant in the overall development of chronic obstructive lung disease in later life.14/ Other studies have examined the effect of chronic involuntary smoking by children on subsequent height and weight development. 15/ The association of chronic ear infections and effusions in children with parents who smoke at home also has been studied. 16/ In addition, the N RC reviewed several studies which show a decrease in lung function in children of smokers, and others which found lower birth weights for babies born to nonsmoki:ig mothers whose spouses smoke, and st'unted growth in children with smoking parents. 17/ Both Reports also recommend that additional research be conducted to further examir.e anl quantify these risks for children and both the NRC Committee and the Surpeon General recommend that parents eliminate smoke from the environment of small chil,:tren. 118/