Tobacco Documents Online

8' C. ACUTE REACTIONS TO TOBACCO SMOKE The reports indicate that there are observable and serious short term, acute physical reactions in nonsmokers exposed. to tobacco smoke. Many nonsmokers experience some level of physical irritation and discomfort in the presence of tobacco smoke. For some, these symptoms may become severe, especiafty in individuals with pre-existing respiratory problems, such as asthma, emphysema, or allergies. 19/ The most com mon acute effects include irritation of the eyes, nose and throat. 20/ Both Reports note that scientific questions have been raised about the impact of tobacco smoke on allergy sensitive individuals, asthmatics and others with obstructive lung disorders. Although the evidence to date is preliminary, several studies have shown that asthmatics experience significant pulmonary impairment as a result of involuntary smoking. 21/ Other sensitive persons, such as those with allergies, may also experience significantly more severe acute reactions to tobacco smoke. 22/ Both reports recommend more research in this area, as well as on the acute cardiovascular effects (51ood pressure, heart rate) in healthy subjects exposed to tobacco smoke. To mitigate the acute effects of involuntary smoking in 80% of nonsmokers, the NRC found that vent0ation rates at least five times those normally required in non- smoking environments are needed where smoking is permitted. 23/ Finally, the NRC found that the benefits of increased ventilation rates are only observable on the short term acute effects of involuntary smoking. The NRC was not able to identify what, if any, ventilation rate would be needed to reduce the risk for lung cancer. Conclusion The reports of the N;tC and the Surgeon General establish that involuntary smoking isa serious public heslith hazard. While future research is needed to more fully understand the complete scope of the hazard, the reports make clear that it can cause lung cancer andisevere, acute effects in many individuals and does pose a particularly serious hazard to infants and children.

9 II. POLICY IMPLICATION5 The scientific conclusion that involuntary smoking poses a serious health hazard is likely to prompt a thorough examination of what actions have been taken and what new policy considerations are raised by these Reports. The home, the workplace, buses, airplanes and other means of transportation, and other public plAces where smokers and nonsmokers mix each pose different policy issues. This section will explore the different sites in which nonsmokers are exposed to b'Dbacco smoke, and examine the alternatives available to address the problem of involuntary smoking in each setting. A. INVOLU NTAft Y SMG KIN G IN THE H O ME The NRC Committee and the Surgeon General recommended that all tobacco smoke be eliminated from the environment of small children. The Surgeon General called parental smoking in the home a form of child abuse. Previous concerns expressed by health offf cials about parents who smoke have focused on the behavioral issues, i.e., parents as role models for chil!dren, and parental smoking as an, implicit endorsement and encouragement to the child to start smoang. The new findings alter these concerns. The fact that smoking in t~he home jeopardizes the health of their spouses, infants and young children raises the question: how can these family members be protected? While the risk of injury in the home is well documented, fewer policy options are available for addressinm these issues in the home than in any other setting. Traditional governmental and judicial mechanisrns for discouraging harmful behavior and apportioning responsibility a nd liability for actions by non-family members outside of the home provide little guidance in this setting. Background N O Ut 0 The protection of chil:#en, and other family members in the home is governed by ~ ~ state law rather than federal law. While these laws vary somewhat from state to state, ~ ~ ~'' they generally apply only to cases of severe abuse and/or neglect, reflecting the

10 consensus that government Intervention into private family affairs is to be tolerated only in crisis-intervention situations to prevent serious, imminent Injury. Typically, government officials have no authority to intervene to protect a child in the home unless a court has probable cause to believe that a child is in serious physical danger or that an ~ emergency exists. 24/ Law suits between family members also have been looked upon with disfavor. For most of this century, family members were not permitted to sue each other. The Doctrine of Interspousal Immunity, followed in virtually every jurisdiction in the United States until about twenty-five years ago, prohibited one spouse from suing another for compensation for wrongful injury. 25/ While this doctrine has been abrogated or limited in all but ten states, 26/ it reflects a still pervasive view that government, in general, and the Courts, in particular, have a narrowly circumscribed role in resolving intra-family matters. Thus, despite the harm smoking can cause in the home, direct government intervention, legislatively or judicially, is not likely. Policy Options Public education is likely to be the most effective means immediately available to protect children and nonsmo;ang spouses from the risk of involuntary smoking in the home. Any such effort would depend upon educational messages designed to make all parents and smoking spouses a N3re of the impact of their smoking on the health of their children and other family members. This public education process requires the involvement of both the public and private sectors. The federal government has the capability both of generating its own educational material and acting as a catalyst for independent efforts by the public and private sectors at the state and local leveL In the ~ past several years the federal government and the private voluntary health sector have 0 initiated public education campaigns directed at mothers who smoke, drink, or use drugs M 0 N to inform them of the harm these habi ts can cause to the fetus. The evidence of the on ~Ph harm caused to infants by involuntary smoking should be incorporated into this and ~ sim ilar cam paigns.

... ~'i'',' . .. . . . + ~.~ 11 The role of government in this educational effort is limited. First, it can dedicate resources to a broad public education campaign about the hazards of involuntary smoking in the home. Second, it can take responsibility for ensuring that those who can deliver the message are motivated and have the information they need. The voluntary health sector, including health professionals associations, and community andschool-based organizations with access to parents are another critical component of an overall educational effort. Specialists such as pediatricians, obstetricians, and gynecologists are in a position to play a key role in disseminating this information to parents and parents-to-be, most of whom look to these physicians for guidance and assistance in caring for their children. Physicians providing pre-natal care are in a unique position to influence the smoking behavior of mothers-to-be and their spouses, both during the pregnancy and after the baby is born. Birthing and parenting classes also present important opportunities to inform parents-to-be of this health hazard to their child. Internists and other general practitioners who provide health care to adults and who are currently warning their patients about the hazards of active smoldng can promote awareness of the hazards of environmental tobacco smoke. Finally, pediatricians who treat children of smokers are in a position to emphasize the sio ificance of the hazards of involuntary smoang and to counsel parents. Private sector efforts need not be limited to heglth professionals. Schools, parent teacher organizations, comm unity recreational and athletic programs and others can educate directly or through school aged children. Another traditional, source of information for and influence in, the family setting is organized relio on. Religious leaders, by providing this information to many adults and children in their congregations who might not otherwise receive it, can contribute to the general public education effort , on this issue as they have on other non-rel!io ous subjects. All of these efforts need to target both parents and children, as experience has shown that as children have been

12 taught about the dangers of smoking, they often have carried this information back to their parents. Given the evidence about the hazards of involuntary smoking, children need to be educated so that they may become advocates for their own health both by encouraging their parents to quit and by avoiding the smoke at home or elsewhere. 4 B. CHILDREN AND INVOLUNTARY SMOKING OUTSIDE THE HOME Children also are exposed to airborne tobacco smoke in environments outside the home. Many children spend a significant portion of their daily life in either day care centers or schools and in waiting rooms in hospitals, physicians' offices and other health care delivery sites. Much of this time occurs during critical years in the physical development of the child when sensitivity to the adverse effects of involuntary smoking may be at its peak. Given the evidence, there is reason for concern about the cumulative exposure of infants and children to tobacco smoke on a regular basis in environments other than the hom e. Background The restraints which limit governmental action in the home do not exist in other settings. Although regulations and laws vary from state to state and from site to site, day care centers, schools, hospitals and other health care delivery sites are subject to government regulation in many states. The question is whether these statutes and/or regulations are adequate to protect t'hese children from involuntary smoking. Currently, smo;dng is leo slatively re?ulated in day care facilities only to the extent they happen to fall within the definition of a "public place" in clean indoor air legislation. Although 27 N O states have enacted some restrictions on smoking in school buIIdinos, only two - Alaska ` and Arkansas - appear to have specifically listed day care centers as public buildings ~ covered by their Clean Indoor Air Act. 27/ These two states do not address the ~ onparticular concerns posed by day care centers. OPA In addition, no data exist as to the number of day care centers which have acted

13 on their own to protect children under their care from involuntary smoking. The data which are available concern elementary and secondary schools rather than day care centers and other pre-school facilities. A 1986 survey by the National School Boards Association (NSBA) of 2000 school districts nationwide found that 87% of the 714 respondents have a written policy and/or regulations governing smoiang in the schools. Approximately half (47% of the respondents) have banned all smoking by students in school buildings, on school grounds, or at school functions. Many others prohibit smoldng by students except in designated areas or outside of the school buildings. However, only 2% of these school district's have similar restrictions on smoldng by faculty and administration. Most school districts (8196) permit smoldng by faculty and administration in designat'ed areas inside school buildings. 72% of the school districts responding to NSBA's survey indicated that the health hazards associated with smoldng were a major factor in~the decision to institute smokang policies, although concerns about role modeling, peer pressure, and compliance with state and local statutes governing the legal' age for purchasing tobacco products, or governing smoldng in public places (clean indoor air laws) were also cited. Even in North Carolina, the leading producer of tobacco, 28 out of the state's 40 school syrtemshave adopted a total ban on smo{dng by students since 1979. Moreover, in Wirston-Salem, the home of RJ. Reynolds Tobacco Company, a 1986 survey revealed that 86% of parents and 62% of students support a total ban on smoldng on school o ounds. 28/ Thirty-two states plus the District of Columbia restrict smo{dng in hospitals. 29/ As is the case with schools, smo;ang policies in hospitals may vary from site to site. Som e hospi tals prohibi t s Tp ~cng only where i t poses a saf ety hazard, such as near combustible rnaterial; others .3ssibn pati~ent beds by smolring status and provide designated smo{ang and non-5mof.zng areas in waiting rooms and other public areas. Still others prohibit smobng throughout the facility or limit it to areas not frequented by patients. 30/ Despite these policies, survey data reveal that smoldng is still widely

14 permitted in patient areas in hospitals and fewer than half have nonsmoking areas in waiting rooms or lobbies. 31/ The rules of the Joint Commission on the Accreditation of Hospitals (JCAH), the organization whose- standards establish the norm in health care settings, require that hospitals have hospital-wide smoking policies, but do not include any standards for such policies. Thus, a hospital may permit smoking throughout its facilities, patient care and waiting areas and meet the JCAH smoking policy requirement. Ironically, while providing little concrete protection for patients, the JCAH standards do provide that smoking must be restricted in areas where equipment, such as oxygen tanks, pose a hazard. Separate from any state, local or privately mandated standards for places where children may be exposed to tobacco smoke, the tort law in most jurisdictions places a burden on those who care for young children to exercise reasonable care to protect them from reasonably forseeable hazards. This duty has been interpreted to mean the exercise of such care "as a parent of ordinary prudence would observe in comparable circumstances." 32/ The recent reports may be particularly significant in establishing liability and apportioning responsibility in these settings because common law tort principles limit liability to those injuries which are reasonably forseeable, 33/ and involuntary smoking-related injuries now are substantially more likely to be found to be reasonably forseeable. While there are no cases reported in the United States involving injuries to children from involuntary smoking in day care centers or similar settings, in light of the newly released findinDs, it would not be unrealistic to expect the courts to be asked to examine the extent to which day care operators and others who fail to take ~ reasonable steps to protect the children under their supervision from tobacco smoke ~O should be held legally responsible for any smoking-related~ injuries suffered by those ~ O children. ~A ~ ~ Gb ~

15 Policy Options Little information exists about protections currently being provided to infants and young children against the hazards of environmental tobacco smoke. No survey data exist and the traditional regulatory bodies have not focused their attention on this problem. Data need to be collected and a comprehensive approatch developed. Direct governmental regulation, particularly at the state and local level, could bring about a rapid change in the protection currently provided. Regulations which govern day care centers, schools, and health care facilities, as well as existing and proposed clean indoor air legislation covering public places and the workplace, should be reviewed~ and examined to determine the extent to which they take into account the particular risks involuntary smoking poses for children. Specific rules to protect children in these settings may be necessary. These could include: prohibiting smoking in any part of a building where the ventilation recirculates the air into areas used by children; and prohibiting teachers and/or caretakers or other employees from smoking if the iinstitution1s ventilation system recirculates air from the roomi(s) set aside for smoking. Private sector initiatives also can have a direct impact. Local and state school boards, school administrators, PTA's, school health providers, relio ous leaders and health, educators are all in a position to bring about appropriate changes in policies governing smoking in and, around' day care centers and schools and need to be made aware of the findings in these reports. Similarly, the Joint Commission on the accreditation, of Hospitals could play a significant role in protecting children, exposed to environmental tobacco smoke in health care facilities by revising their requirements. Organizations ' like the American Society of Heating, Refrigerating and Air Conditioning Engineers, Inc. (ASHRAE), which produce rvi;:ely accepted minimum ventilation and indoor air quality ~ rates also need to revievv and revise their current standards to take into account the hazards of involuntary smow ng.

16 C. INVOLUNTARY SMOKING IN PUBLIC PLACES Nonsmokers are exposed to tobacco smoke whether or not they live with a smoker or work in a place where smoking is permitted. It is virtually impossible to live a normal existence without being exposed to some level of tobacco smoke during some part of the day, whether the exposure takes place in grocery store check out lines, restaurants, 4 municipal buildings or at sporting events or public meetings. The reports of the Surgeon General and the National Research Council base their findings on studies which document the long-term health hazards to individuals who breathe tobacco smoke in the air at home. These studies do not isolate the effects of the repeated short-term exposure which occurs in public places. Nonetheless, the data provide reason for concern about the cumulative effects of tobacco smoke exposure in public places. Both reports point out that exposure to tobacco smoke, even for a relatively short period of time, commonly causes acute effects, such as eye, nose and throat irritation and may cause more serious acute effect's in highly sensitive individuals. Both reports also provide reason for concern that this short-term exposure may contribute to the increased risk of lung cancer for nonsmokers, because it contributes to the overall amount of tobacco smoke a nonsmoker inhales, a fact which may be of particular concern for those also exposed at home or at work. Thus, while the primary health effects of repeated short-term expasures in public places are the more visible acute effects, the cumulative impact of these exposures in conjunction with exposures in the home and wockplace also should be considered in determining what steps are necessary to protect nons;nokers. Background The Surgeon General's report defines a public place as any enclosed area in which the public is permitted or to which the public is invited. 34/ Examples of public places include, but are not limited to educational facilities, health care facilities, public transportation facilities, reception areas and areas open to the general public in office

17 buildings and government buildings, restaurants, grocery stores, bars, sports arenas, retail stores, theaters, and waiting rooms. In short, a public place encompasses almost any place the public is permitted outside the home. Smoking in public places poses different issues than either smoking at home or at . the workplace and these distinctions affect the policy alternatives available to protect nonsmokers. Traditional restraints against governmental intrusion into the home and against judicial interference in family relationships do not apply, and, thus, direct legislative and regulatory action is likely to continue to be the most widely used mechanism for protecting nonsmokers in public places. While the judicial system has acted as a catalyst for public and private sector action to protect nonsmokers in the workplace, the Courts have played virtually no role in prompting action to protect nonsmokers in public places. The reasons for the judiciary's lack of involvement in, protecting nonsmokers in public places differs from the reasons why it has played no role with regard to smoking in the home. While public policy considerations limit government and judicial involvement in protecting family members in the home, the major impediments to judicial involvement to protect nonsmokers in public places have been factual and scientifie. Store owners and others responsible for public places do have a legal obiioati~on to exercise reasonable care to keep their premises in a safe condition, to discover dangerous conditions and to rem edy them in order to protect those •Kho enter the premises. 35/ Owners and custodians of these public places are not insurers of the safety of their visitors. Their duty is to exercise "reasonable care,"' SuC that oblib tion extends to everything that threatens a visitor with a forseeable, .Lnreasonable risk of harm, unless the visitor is aware of the dangerous condition and' knowingly exposes himself to that risk. 36/ An essential element of any lawsuit seeking damages for personal injury is the ability to prove that the injury, in fact, was caused by the action or inaction of a particular party or parties. Normally, a person in any one public place is exposed to