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® 0 0 TOBACCO SMOKE AND THE NONSM public policy aspects of passive smokj&, A review of the scientific a-spects and commentary azl the ~ T OII 11CACAO Advisory Council 0

TOBACCO SMOKE AND THE NONSMOKER TABLE OF CONTENTS Page INTRODUCTION ................................................................................... . .....2. AMBIENT TOBACCO SMOKE AND HEALTH CLAIMS .................................3 An Overview ..................................................................................................3 Health Claims ...............................................................................................4 Lu ng Cancer .... ...... ... ........................ . . . ..... . .. . ...... ... ...... . ........ . . . . . ...... . . . . ...... ... . .4 Respiratory Diseases: Lung Function ............................................................5 Comprornised'Individuals: Respiratory Diseases ...........................................5 Cardiovascu lar Diseases ................................................................................6 Compromised'Individuals: Cardiovascular Diseases ......................................6 Childhood Diseases .......................................................................................7 Allergy............................................................................................. ...............7 Building Illhess ...............................................................................................8 AMBIENT TOBACCO SMOKE AND THE PUBLIC .......................................9 Regulationiand Individual Right's ............................... .....................................9. REFERENCES ................................................................... .......... ........... ..... 10 Tobacco Advisory Council Glen House: Stag Place London SW 1 iE 5AG Te4: 01-828 2803/2041 December 1985

INTRODUCTION The issue ofi"public smoking", which arises from health claims about the exposure of nonsmokers to ambient or environmental tobacco smoke (often referred to as "passive smoking") appears frequently in ~the media„and has generated considerable public concern. The restriction or banning ofi smoking in public places is claimed by some as being necessary to protect the "rights" and the health of the nonsmoker. This is part of a campaign to make smoking socially u nacceptable, Many claims have been made about the aileged health effects of "passive smoking", notably that exposure to ambient tobacco smoke causes lung cancer, other diseases of the lung, and heart disease in nonsmokers. The studies which have been used to justifythese claims have been criticised by independent scientists and at international conferences. Moreover, other studies on "passive smoking"' do not justify the claims of adverse health effects at aIV. For anti-smokers the scientific validity of such health claims is rarely an issue in public discussions on this subject; rather it is the emotionall impact of the claims which is given prominence. A participant at the Fifth World Conference on Smoking and Health (1983) stated: "Regardless of the ultimate validity of the findings, which ~remains to be established,, studies such as these have brought~ the issue of passive smoking to the public's attention."" Because it appeals to emotion, the issue of the nonsmoker's health has become the basis for legislation regulating smoking in public places and banning smoking in workplaces. 2 The purpose of this paper is to survey the current scientific literature on "passive smoking" and'rto discuss the implications of the scientific opinion considered initerms of the public smoking issue. The opinions of various experts and authorities on the possible health effects of tobacco smoke on the nonsmoker are examined. The weight of the opinions examined suggests that~no clearr scientific case has been established on health grounds for the restriction of smoking in public places and the limitation of the personal lactivity of~ individuals.

AMBIENT TOBACCO SMOKE AND HEALTH CLAIMS An overview Several highly pubiicised studies have been offered as "proof" that tobacco smoke is harmful to nonsmokers. Thestudies most frequently cited are those by HirayamaF and Trichopoulos and co- workers3, who reported that nonsmokers exposed to tobacco smoke have a higher risk of developing lung cancer than nonsmokers not exposed to tobaceo smoke, and by White and Froeb4, who reported that nonsmokers with long+term exposure to tobacco smoke in the workplace have significantly reduced small-airways function. Other reports suggest that children, and individuals with lung and heart disease are adversely affected by exposure to ambient tobacco smoke, Hbwever,critical examination of these studies by independent scientists and by medical experts at international conferences, together with other studies which have found no significanfassociation between ambient tobacco smoke and'adtrerse health effects;,suggest that such health claims are not based on unequivocal scientific evidence. Obviously, the claim ~that exposure to ambient tobacco smoke is a known cause ofidisease in, nonsmokers carries a great deal of emotional weight. However, scientists have warned of the danger of permitting emotion and!fear to obscure the scientific facts about public smoking. For instance, Dr. Gio Gori, a former U.S. National Cancer Institute director recently stated: "What needs to be Stat~ (~ despite numerous'arja ~ trials, available evidenc e .,,, , been found'that a'massi health problem attribu~b passive smoki' nge~i; An international symposium held in 1983 at1he University of Geneva, to discuss scientific developments in this area concluded: In May, 1983, scientists and epidemiologists at a workshop on "Respiratory Effects of Involuntary Smoke Exposure: Epidemiolog ic Studies" sponsored by the U.S. National Institutes of Health concluded: Scientists atThe "International Symposium on Medical Perspectives on PassiveSmoking"; held inVienna in April, 1984„and co-sponsored'by the German and Austrian Societies for Occupational Medicine, and in co-operation with the World Health Organization (WHO) and the International Green Cross, stated in a press release that legislative measures intended'to "protect"' people from ambient4obacco smoke exposure could not be justified by the available health data.8 Dr. Lehnert, at this symposium, came to the conclusion that: In his opinion, "all the epidemiological studies carried out so far lack the appropriate methods to determine the extent of exposure to passive smoking." Other organizations not known ~for theirsupporfof smoking have also questioned whether there is sufficient scientific evidence to substantiate these claims against passive smoking. For example, in the United Kingdom, the Royal College of Physicians' fourth repoft (1983) on smoking and health noted that "the extent'to which ~passive smoke exposure can damage the health of~ otherwise healthy individUals is by no means clear"10 Another review in the U.K., the Third Report of ithe Independent Scientific Committee on Smoking and Health1 (1983), stated: A 1983 World Health Organization stUdy stated thaV"although i epidemiological studies have been undertaken to investigate the possible carcinogenicity of passive smoking and its relationship to respiratory diseases, further work is clearly required."12 And while the 1984 U.S. Surgeon General's Report in~relation to chronic obstructive lung disease discussed the issue of ambient tobacco smoke at length, it conceded that "limited existing data yield conflicting results concerning the relationship between passive smoke exposure and symptoms in patients with known, pulmonary disease."13 3

AMBIEHT TOBACCO SMOKE AND HEALTH CLAIMS I Health claims Many claims have been made aboutt the alleged health effects of ambientt tobacco smoke, Among the most frequent are that smoking in the home and in public places, especially the workplace, causes lung cancer i and heart'disease in nonsmokers and that~ it is particularly harmful to those who alteady have respiratory and heart disease. It is appropriate to consider the various opinions I presented in support of these serious accusations. , Lung cancer Two research papers are frequentlyy cited to support the claim that public smoking increases the nonsmoker's risk of lung cancer. A study of Japanese women by Hirayama reported that nonsmoking wives of heavy smokers have a greater risk of developing lung cancer than nonsmoking wives of~nonsmokers.2 In a study of Greek women, Trichopou los and~co-workers, concluded that a nonsmoking woman whose husband smokes has twice the risk of developing lung cancer as a nonsmoking woman imarried to a nonsmoker.3' Both studies have been criticised in the scientific literature. Inconsistencies in the Hirayama study have been pointed out; questions have also been raised about the design of the studyand the validity of its conclusions.1112 'The 1983 University of Geneva symposium on environmental tobacco smoke noted that the study has been criticised'forlack of questionnaire reliability, absence of histological diagnosis„questionable statistical!treatment and grouping of smoking habits among husbands,, and failure to examine such factors as air pollution from heating or cooking or, both.23' Criticisms of the Trichopoulos study were acknowledged by the authors in the 1983 update of their study.241They noted that the study had been "criticised by ourselves and others because of the small number of subjects, because several tumours lacked'histological confi'rmation~ and because controls in ~cases were from different hospitals."' However, Garfinkel, of the American Cancer Society (ACS)?5' reported'on data from an ACS 1960= 1972 follow-up study, involving nearly 180,000 nonsmoking women. By comparing the lung cancer, mortality rates of women reportedly exposed to different levels of~tobacco smoke, Garfinkel determined that none of the observed differences were statistically significant and that "compared to nonsmoking, husbands, nonsmokers married to smoking husbands showed very little, if any, increased risk of lung cancer; °' The 1982 U.S. Surgeon General's Report on cancer analysed these early studies and indicated that there was insufficient evidence to conclude that other people's smoke causes disease in nonsmokers.26 One of the co-authors of that discussion subsequently wrote that "the qwestion of the effect~of involuntary smoking on lung cancer has suffered' from confusion and'inappropriate, as well as conflicting, findings."27 Since then, several other studies have investigated the issue of lungg cancer in nonsmokers, with contradictory results. A study, by Kabat and Wynder published in 1984, exarnined 25 male and'53 female nonsmoking ilung cancer patients. The researchers found no difference between female cases and controls with regard to their home or work exposure to environmental Itobacco smoke nor in the proortion of smoking husbands. 8'More recently, Garfinkel lin a hospital Icase-controV study in the USA of~exposure of women to environmental'smoke between 1971 and 1981 suggested a trend towards a higher incidence of lung cancer but only a marginal I increase after exposure to the smoke from 40 cigarettes per, day2`' However, the study was unable to distinguish between rthe effects of moderate or prolonged exposure over 5 to 25 years. A study from Hong Kong found fewer "passive smokers"'among lung, cancer patients than among controls. The authors noted that "this finding is at variance with that of, Dr. Hirayama's."3o. Another study done in Hong Kong concluded that "passive smoking, as an isolated factor, did not have an influence on female lung cancer incidence in Hong Kong."31 Other recent studies have claimed to support Hirayama's conclusions, but close examination by others of the methods and conclusions of these studies suggests that their claims may be unfounded. For instance a 1983 report from Germany, which identified 39 nonsmoker lung cancer cases, asserted that exposure to tobacco, smoke was the "most plausible explanation" for the reported'Iting cancers.32 One reviewer disputed these findings and characterised the study as containing "only tentativee conclusions based on poor data analyzed~ b unacceptable methods." 3 Another 1983'study„from the U.S., reported an increased risk of lung cancer for nonsmokers married !to smokers.34 The authors concededJ however, that the numbers studied were smalll I n 1984, a U. S. researcher reported that nonsmoking women married to smokers had a higher percentage of cancer deaths than those married to nonsmokers.35 However,the data indicate that the percentages of cancer, deaths were higher for women workers married to nonsmokers than those married to smokers. As noted'above, the scientists at the 1983 University of~Geneva: symposium concluded that an increased risk of lung cancer to nonsmokers from tobacco smoke exposure "has not been established;"e More recently after a thorough review and analysis of the published papers on the topic of lung cancer and the nonsmoker, scientists and physicians afthe 1984 Vienna meeting concluded that'no link has so far been scientifically established between "passive" smoking and 4

lung,cancer9 ~ Respiratory diseases:Lung Function The question of respiratory disease in nonsmokers was raised in a 1980 study by White and Froeb.4 The authors measured the small-airways function of smokers and nonsmokers. They concluded that nonsmokers who were exposed to tobacco smoke at work for 20 or more years had reduced'function of the small-airways compared to nonsmokers who were not exposed. In 1983, French researchers reported that nonsmoking spouses over 40 years of age who were married to smokers exhibited small but statistically significant decreases in pulmonary function compared to nonsmoking spouses of nonsmokers.36 The White and Froeb study has been criticised for various reasons:3'-ao A physician at a UIS. medical school iquestioned'the authors' use of carbon monoxide as an index of smoke exposure,, contending that they'`do not have reliable estimates of the smoke exposure in the environment of their, nonsmokers" because carbon monoxide is not unique to tobacco smoke:40' Based upon his own analysis of the White and Froeb study, a British reviewer concluded that the authors' findings "relate to an index which is contentious and certainly not an accepted reliable indicator of an increased health risk."15 White and' Froeb themselves noted that the average values of itheir pulmonary tests of nonsmokers exposed to tobacco smoke "were not notably different"'from the values suggested as normal by a specialist in this area;`" A critical assessment of the White and Froeb study was made by Lebowiti at the 1982 annual joint meeting of the American Lung Association and American Thoracic Society. He reported that the study was "improperly designed" from an epidemiological point of view. He cited many problems including the selection of the group to be studied, the proper measurement of smoke in the workplace and'other confounding factors. Lebowitz thus urged that the study notbe used to support4he claim ~that'environmental tobacco smoke in the workplace affects the lung function of adults.42 The authors of~the 1983 French study reportedly found significant differences in lung function in only one group of~theirstudy population; they reported no significant differences between exposed and nonexposed nonsmokers in the population as a whole. One commentator noted thatthe "healthiest" population in the study lived'in the most polluted areas, suggesting that the study may have been flawed due to biasedpopulation selection or, other confounding I variables.a3 Furthermore, the White and Froeb and the French study conflict with, other research on lung disease and lung functioniin nonsmokers. For example,,in 1981, several epidemiologists at a U.S. medical I school Ireported that in a group of 1,724 adults the frequency of respiratory symptoms in nonsmokers was not associated'with the number of smokers in the household. Nor was the frequency of impaired ventilatory function significantly higher if there were smokers in ~the house.44 The analysis did however show that '°among men who never smoked cigarettes,,gas cooking was defrnitetyassociatedwith impaired ventilatory function, even when, corrected for multiple comparisons." These results were confirmed by the same research group in a follow-up study of 708 nonsmokers later that year.45 In 1983, U.S: researchers reported that in a study of several hundfed nonsmoking women from a U!S. study population, there was no significant association between lung function decrement and exposure to tobacco smoke in the home.4s Coordinators of an epidemiological study ofiobstructive lung disease in a southwestern U!S. state have: consistently reported finding no effects from ambient tobacco smoke exposures in their adult study population.47ln a study of 376 families in U!S. homes, university scientists found no evidence that environmental tobacco smoke affected either lung function or symptoms in adults."8 A U.S. pulmonary physician and clinical professor of medicine summariied'the situation at the 1983 I University of Geneva symposium: "Studies, to date, of long-term effects of (environmental tobacco smoke) on lung function have revealed minimal, if any, abnormalities. The statistical significance of these findings is questionable and the clinical significance is even less certain."49 The participants at the U.S. National I hstitutes of Health workshop on respiratory effects of exposure to tobacco smoke concluded;,after a review of the data: from relevant studies, that a possible effect from environmental Itobacco . smoke "varies from negligible to quite small."' Compromised Individuals: Respiratory Diseases Asthmatics are believed to be particularly vulnerable to various environmentaliinfluences, including tobaccosmoke; A 1981 study, for, example, reported "significant" decreases in the pulmonary function ofiseveral asthmatics exposed to tobacco smoke.50 The subjects in, this study were exposed to tobacco smoke in an environmental smog chamber, an environment not typically encountered by nonsmokers. Moreover, because half of the subjects reported that they were bothered by tobacco smoke prior to the start of the experiment,, the authors said that they were "not able3o exclude the possibility that these changes in pulmonary functionn were emotionally related to cigarette smoke." A group o` U. S. university researchers noted in a 1983 study that asthmatics exposed!to tobacco 5

AMBIENT TOBACCO SMOKE AND HEALTH CLAIMS smoke did not exhibit airway reactions or decreases in airflow rates.51 A Canadian group who examined' the reactions of asthmatics to levels of tobacco smoke typicalllyfiound in public places observed no systematic lung changes after such exposure.52 A later report by the co-authors off this study supports this conclusion. They reported that respiratory data collected from a group of asthmatic volunteers exposed to tobacco smoke "do not suggest that asthmatic subjects have an unusual sensitivity" to such exposure.53 Although several volunteers claimed that they experienced wheezing and tightness of the chestdue to the exposure, the researchers state that the "physiological data give little support totheirconcept of a subgroup with particular sensitivity."' They noted that these reactions probably were due to the "suggestibility" of the subjects. Recent research from Australia supports the theory that psychological reactions may partially explain asthmatic symptoms during exposure to ambient tobacco smoke. This study reported that while asthmatics exposed to tobacco smoke complained of subjective symptoms, no significant objective evidence of airways obstruction was observed.54 In 1984, a: report on resuits from a large-scale epidemiological study in the U.S: suggested that ambient tobacco smoke in homes did'not affect symptoms of pulmonary function in ~either children or adult asthmatics.55 The researchers reported!,however, that everyday exposures to dust and'pollen in the home did. In addition, the 1984 U!S. Surgeon, General's Reporti stated: -F`i^s v'Cl,'! 6 Cardiovascular Diseases It has been claimed that carbon monoxide from ambienCtobacco smoke causes or contributes to the development of atherosclerosis or thickening of the arterial blood vessel', walls in nonsmokers. Eariy studies by a Danish researcher,Astrup; are frequently cited in support of this claim. In these studies, he reported finding arterial changes not apparently different from early atherosclerosis in animals exposed for, long periods of time to carbon monoxide and fed a:high cholesterol diet.56 When Astrup attempted to reproduce those changes in later experiments however he was unable to do so.57-5k Following additional experiments applying similar criteria to those used in their earlier studies, he and his colleagues reportedly found "no hiptotoxic effect" of carbon, monoxide on the inner layers of coronary arteries or the aorta;59'and concluded that "thereis no longer evidence for considering carbon monoxide to be a component of major importance for enhanced atherosclerosis in tobacco smokers:i60' The authors of a study in which monkeys were exposed tot+lgh levels of carbon monoxide stated that'data "do not suggest any association between periodic carbon monoxide exposure and the developmentof atherosclerosis" in these monkeys.61 One of the researchers involved in that study stated~ in 1984 that while he was aware of the claims aboutt carbon monoxide and'heart disease in nonsmokers, "animal work in our laboratory and others leads me to conclude that periodic exposure to carbon monoxide from atmospheric tobacco smoke will not predispose nonsmokers to atherosclerosis.'"6Z Rylander, aYthe summing up of the 1983 Geneva symposium, concluded that "carbon monoxide from environmental tobacco smoke is not important from a health point of view."g The 1983 U.S. Surgeon General's Report„which dealt with cardiovascular disease, did nott address this issue in any systematic fashion.r~3 A spokesman for the Office of Smoking and Health for the U.S. Department of Health and~ Human Services explained that there was insufficient evidence to support any conclusion on the matter.6 Compromised Individuals: Cardiovascular Diseases A 1978 study by Aronow reported' that ambient tobacco smoke can harm persons with preexisting heart conditions.Jn this study of 10 heart patients, Aronow concluded that exposure to tobacco smoke caused heart pain to develop sooner during exercise than without such exposure.65 This experiment has been severely criticized by a number of: authorities,66 including the U.S. Surgeon General.6' A professor of, pathobgy stated'thatthe study must be "evaluated in light of the fact that the end-point of the study was highly subjective, that the stress factor was not controlled, and that a sham smoke or other environmental impingement was not used; In~other words;, not only was the sample small, but the scientific design was exceedingly poor"se After reviewing the Aronow study, a Canadian professor of medicine commented that "it is difficult to imagine that enclosure in a very smoky room did not have some emotional impact upon patients who were liable to angina, and'the psychological disturbance may have done more to hasten the onset of symptoms than the increase of blood carboxyhaemog iobi n.'"69 In 1983, British researchers reported on measurable responses of i a group of heart patients to amb!ent tobacco smoke exposures. They reported no physical response in the patients to any level of exposure.'o In 1983, after a U.S. governmental agency reported problems with certain studies Aronow had performed on its behalf; another, U.S. governmental agency conducted an independent review of several of Aronow's studies. The latter agency concluded that, because ofiproblems

with the studies' design and data; it could no longer rely on his research to formulate environmental standards.".7z Childhood Diseases Perhaps nothing in this area is as capable of,provoking ! public comment as the various claims that parents . who smoke harm the health of their children. A discussion of the issue is further, complicated by the many differences inrthe studies in this area. In the United States, according to one report, studies of ambient4obacco smoke and the respiratory system are being °carriedout by at least three different groups, are employing different'populations and methodologies and have led to varying conclusions.'"' While certain~studies have reported adverse findings,'s-a7 others have found'no significant relationship between parental smokin~ and children+.s respiratory illhess: '95 For example, a group of U.S. researchers found "no significant relation" between parental smoking andlrespiratory symptoms in a study ofinearly 400 families with~ a total of 816 children in rthree cities.aa The authors of some studies reporting adverse findings state that their conclusions must be viewed with caution because of numerous so-called "confounding factors". For example, one group of British, researchers acknowledged the possible influence of factors such as cross-infection in the home and genetic susceptibility to childhood respi'ratory ilVness and . symptoms.'s, 77;.98 Others have conceded that the reliance on qNestionnaires for information about respiratory symptoms casts doubt on the findings.80'Another study observed that there was a significant~ difference in the respiratory symptoms reportedl depending on which parentt completed the questionnai're,ss The importance of suchi confounding factors was given ~'special Iconsideration in the report from ithe 1983 workshop sponsored! by the U.S. Natlonal'Institutes of Health.' Among the many confounding factors which were listed in the report weretype of i heating used, socio•economic status and'other variables affecting household conditions,,including the number of residents,,demographic and medical characteristics of the study population such as age, parental symptoms and annoyance responses. It cautioned "that any study which ignores them will be seriously flawed." The relevance of such factors in affecting the outcome of research findings is supported for example by British reports which have shown that the use of~gas cooking stoves in the home is strongly associated with childhood respiratory disease.99- 98 A number of studies examining the relationship between parental smoking and pulinonary or, lung function also have contradictory findings. Although severallhave claimed that parental smoking results in decreased pulmonary or lungg function in~children,76-6,9s-1o2 others have not.47, 4e, ss, ~a3, 104 In 1982, for example, a U.S. group of researchers reported that its analysis of 344 families "did not show any significanti correlations of passive smoking with pulmonary funetion"'after the influence of body size on lung function was taken iinto account.' 05 Two years later, a re-analysis of families from this study group again showed that "parental smoking did' not have a significant effect on children's pulinonary function; smoking habits of others in the household (predominantly si,biin7qs) did not have anyeffecteither."4 Questions have also been raised regarding the long-term significance of the reported decreases in pulmonary function. The most recent report of the U.S: Surgeon General (1984) on this subject noted that the absolute differences in lung!function, observed in such studies are "small" and "unlikely" to be of functional significance.10 Allergy Although some individuals are annoyed by the sightland smell of tobacco smoke and a:few report experiencing irritation, statements by various authorities suggest'that the existence of human allergens in tobacco smoke has not been established. Theiast U.S, Surgeon General's Report to deal with this subject (1979) pointed'out thati°the existence of a tobacco smoke allergy in humans is unproven."106 In~1980, a group of researchers noted.that "direct evidence that tobacco smoke is immunogenic (capable of~evoking a specific response), in man is yet to be documented."'10 Although an English immunologistl noted that there may be substances in tobacco smoke which could "theoretically" act as such agents, he concluded that "there is no proof that the specific sensitization to tobacco smoke exists.'"oe A research group headed by Becker reportedly has isolated a substance from tobaecosmoke which it claims is an allergen109-"'' and which it speculates might be responsible for pultnonary andl cardiovascular diseases in smokers."' However a former director, of research with the U.S. DepartmenUof Agriculture concluded, "I am not convinced that Dr. Becker and his colleagues have extracted'a human allergen from either tobacco smoke or tobacco smoke condensate. Further, it appears the separation procedure that they used int'roduced'a substantial artefact.""2 He reaffirmed his conclusion ~in a later research report on this subject.13 It has also been hypothesized that tobacco smoke is capable of i provokin~ asthma as an allergic reaction,.14. "5 A Swedish specialist concluded that such results are nott proof of a tobacco allergy because the studies, which used tobacco extracts,,did not~differentiate between nontspecifie and allergic reactions in evaluating the results of skin tests and bronchial!provocation.16 Consequently, he stated! "for the present, the question as to whether

AMBIENT TOBACCO SMOKE AND HEALTH CLAIMS allergy to cigarette smoke exists or not should bekeptiopen." While there appear to be people who may be sensitive to tobacco smoke, there is evidence suggesting that personal annoyance and emotionallreactions are being confused with genuine allergic reactions: The director of an allergic disease centre in the U.S. has suggested'that reported reactions to tobacco smoke may be irritative rather than allergic. After reviewingg the studies on the aiiergy question, he concluded that "there is no proof that~ tobacco smoke is allergenic in man.'" 117 Researchers at a U.S. clinic failed to find any evidence of tobacco smoke allergies in their tests of subjects who considered themselves aliergic to tobacco and tobacco, smoke.18 Conseqpentiy, it~ maybe that when ' peopie say they are "allergic" to tobacco smoke, they may simply not~ like the sight and'smeli of tobacco smoke and interpreY4histo mean that they are "allergic" to it. Building Illness Conditions in modern office buildings have given rise to numerous worker complaints. These range from headaches, nausea and eye irritation to fatigue and'breathing difficulties. This complex pattern of symptoms has been conveniently labelled "building illness." It is claimed that~ambient tobacco smoke is the cause of such symptoms and complaints among workers. This claim is not consistent~ with much experfopinion reported in the scientific literature about "building illness" syndrome. Studies have shown that the contribution ofi tobacco smoke to the workplace atmosphere is proportionately much lower than that~of vehicle exhausti dusti building materials„and other gases and'aerosois.''' 9'' 21 Papers presented at an international symposium oniindoor air pollution suggested that~some building illness complaints may be linked to such ~ diverse materials as carpet shampoo„particle board and 8 ultravioiet lighting.122_'2° On the other hand, these studies have not found that tobacco smoke was the cause of these complaints. Researchers attending the 1983 University of Geneva symposium reported on their review of over 150 health hazard and indoor air quality evaluations for office buildings compiled by U.S. government agencies, universities and others. The authors concluded: "The review of avaiiable studies does not provide any objective evidence that~either pollution levels or patterns of health-reiated' complaints differ in some remarkable way between locations with or without smoking restrictions."12,5 They did observe that "inadequate" ventilation may create conditions "where discomfort and illness result irrespective of whether or not smoking is permitted." Several questionnaire surveys of building sickness in the U.K. have shown the prevalence oficompiaints to be independent of smoking.126•'z'' A recent cross-sectional study on office workers performing similar clerical and manageriai'jpbs in adjacent buiidings concluded that most of the respiratory, eye and nasal symptoms in air-conditioned buildings are related to the ventilation system.' 28 Canadian researchers have suggested that the mere visibility or, presence of tobacco smoke in such cases may trigger claims that it is the cause of reported symptoms and complaints. When they exposed "healthy" nonsmokers to tobacco smoke under conditions some described as "the worst they have ever experienced,!':oniy "minimal" physiological or actual physical responses were observed:' 29 The researchers conciudedithat~ "the main argument for smoke free air seems symptomatic rather thann physiological." One Swiss researcher noted'that in fiel6studies, "individual psychological factors (relationship with smoking co-workers, generalljpb satisfaction, attitude toward~smoking) may considerably influence the individual evaiuation of irritation and' annoyance."' 3° Comments such as these suggest that1he use of, health arguments in support of smoking bans in the workplace is notJustified by the evidence on the subject. #. t

AMBIENT TOBACCO SMOKE AND THE PUBLIC REQrULATION AND INDIVIDUAL RIGHTS As this review has demonstrated, there is a need for placing the health claims on environmental tobacco smoke into a proper perspective. This is aptly summarised by a press release from the Vienna Symposium: "Should lawmakers wish to take I legislative measures with regard to environmental!tobacco smoke, they will„for the present, not be able to base their efforts on a demonstrated health hazard from environmental tobacco smoke."8 In essence, the issue is of a political and'social nature. Whilst acknowledging that it is capable of raising,strong reactions from those who intensely dislike smoking - although the extent of annoyance under normal conditions has not been established scientifically6 - it has been suggested'that tobacco smoke is at most a minor annoyance which can be eliminated'by adequate ventilation,' 31 - ' °2 The annoyance factor, has itself to be seen in a proper context and!those who advocate regulation should consider whether the same reasoning applies to other annoyances in everyday life. It seems clear thatlhe regulation of smoking in public places, simply because it may annoy or irritate some nonsmokers, constitutes an unwarranted restriction on the freedom of~those who choose to smoke. There is undoubtedly a need for the promotion oficourtesy and this is a solution which relies on commonsense and freedom of choice for individuals concerning smoking. As a recent article on the principles of, public policy relating to smoking has pointed!out„ "the appropriate#orm of public policy is the promotion of courtesy and'co- operation between smokers and non- smokers, rather, than outright prohibition."'33 Such a solution avoids unnecessary administrative interference and the subsequent curtailment ofiindividual freedom which would be occasioned if Government action were contemplated. 9 I

REFERENCES 1. Warner, K., "Toward a Global Strategy to CombafSmoking: The 5th World Conference on Smoking and HI J Public Health Pol. 5(1): March~ J984, pp. 28-39. 2. Hirayama, T, "Non-Smoking Wives of Heavy Smokers Have a Higher Risk of Lung Cancer: A Study from Japan,"Br Med J I t 183-185. January 17,1981. 3. Trichopoulos, D, et al., "Lung Cancer and Passive Smoking," lnt J Cancer 27 (1): 1-4, 1981. 4. White, J. and H. Froeb, "'Smalll-Airways Dysfunction in Nonsmokers Chronically, Exposed to Tobacco Smoke, "' New Engl J Med'302 (13): 720 723, March 27, 1980. 5. Gori, G, "Sidestream Smoke-Fact and Fictiona" ASHRAE Transactions, 90 19841 6. 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Follow-up Report of the Royal College of Physicians, (London, Pitman Publishing Ltd,,1983), pp. 72-81. 11. Froggatt, P Third Report of the lndependent Scientific Committee on Smoking and Health (London: Her Majesty's Stationery Office, 1983). 12. World Health Organization;,"Indoor Air Pollutants: Exposure and Health Effects: Report on a WHO Meeting,"June 8-11, 1983, Nordlingen, EURO Reports and Studies, 78. 13. U.S. Department ofiHealth and Human Service, "Chapter7. Passive Smoking "' The Health Consequences of Smoking:,Chronic Obstructive Lung Disease. A Report of the Surgeon General; U.S. Department of Health and Human Services, Public Health Service, Office of the Assistant Secretary for Health, Office forSmoking and Health, DHHS'Pub No DHHS (P45) 84-50205. 1984, pp. 363-410 14: Diamond, G. and JJ Forresteq "Clinical Trials and Statistical Verdicts: Probable Grounds focAppeal," Ann Intern Med 98 (3): 385-394„March,~ 1983. 10, 15. 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® Tobacco Advisory Council Glen House Stag Place London SW1E 5AG Tel: 01-828 2803/2041 December 1985. 4