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ETS - Environmental Tr..)Ibacco Smoke Report from a workshop on s effects and exposure levels March 15-17, 1983, Geneva, Switzerland Editors: R. Rylander, Y. Peterson M.-C. Snella European lournplof Resperat®ry Diseases Supplement No.133, Vol. 65, 1984 MUNKSGAARDICOPENHAGEN

Contents PRFFACE ..................................... 5 IIr1TRODUL"IION ................................ Jt.rw R,%L.J.. 7 L f.XPOSURELEVELS .............................. 9 1'.1. Fs.ixonmeatal tobacco smoke measurenunn: retrospect and Prospcct . Xd.. W. Firu 9 12 IanestiQstioru on the e$cct of regulatin` atsoking on le.eL of indoor Pollutioa and on the perception of health .nd' costfort of office .orken 7irr1.. D. Sa.ft .d F.lic N. SM*q 17. 1.3. Aa.l7tical chcminl methods for the detection of cn.irontnental tobacco smoke conatitucats ............................. , R.arr A. Je&Eiro wd AJ1rb..l R. Grria 33 1.4. Carbon anonoside as an indei of environmental tobac6o smoke eapo- aure .........., ........................... 47 Dwerrt. Af. Aw.d. 1.5. Discuuion . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . R:ppor;eun: Al.rrsT fj fs+sii ad Cer+ulYr f Lwb 61 L'd HU•5ANS . . . . . . . . . . . . . . . . . . . .. 63 Z 1. }iaJI-lix•n of ulcr.cd tobacco stnake e=posure markers . . . . . . . . . Ccrw _u f. Lp-b fj 22 Afcuurcmcnr and estimation of smoke dosagc to non-imoken from en.i- t=meatsJ' tobrcco smoke . . . . . . . . . . . . . . . . . . . . . . . . . . 5 A! R X 68 sn Xet,r f. fosir wI. 1=6.r! A . 2.3. Walidit7 of questionnaire data on smoking and other esposuies, with speciad refettncc to enr'ronmental tobacco smoke . . . . . . . . . . . . . . Gina Pnm.:rn . 76 2.4 Disc-.is!ion . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 8U RaPPoracurs: lCos...4; fiw4rv.ni raro1.. D. Su*t.xj 3

3. EFFECTS IN HUMJSJS .............................. 8s 3.1. Doea en.iroomearxl tobacco satoke a@'ees lung fuaction?' ........ djft Q.ir 8S 3.2 Ea.itonmeatal tobaccco smoke and puk~ inoctson oesang .... A.e6.? M. Ca.miA. 3.3. The eSms of enviroamentali tobacco stnolte espostue and gaa sto.es on 68 dail7 peak flow rates in asthmatic and ~ noo- asthmatic Eamilica ..... Mird..f D. Li+.riz 90 3.4. Acute effccts of environmental tobacco smoke . . . . . . . . . . . . . . iL..rru V.Bfir 98 3.5. Respintory, srmptoms in the children of smokers: an overview ..... P.nrt.E G. FIoU nu' Knm f. Trrnv. 3,6. The cfkct of environmental tobacco Tmoke in two urban communities in 109 the West of Scotland . . . . . . . . . . . . . . . . . . . . . ., . . . . . . CAv+u R. Gillit, Dawd f•., L, V'ut.r .ll. Xtrwrbornm mrd Pu.r 8e)u 121 3.7. Environmental tobacco smoke and lung cancer . . . . . ., . . . . . . . R.~o R)l.nd.r 127 3.8. Discusaion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . R:pportetius: Co+mr Pnrd+Sm .el Aubnrj M. C.vrier 134 4. WORK GRCUP RESULTS ........................... 137. 4.1. Exposure ................................... . Chaartnaa and rapporteut: .1Glwn Ii'. firrt 137 4.2 EfCccts on health .............................. . Chairman: rLlicAwl r!. H. Rrruu Ra? pc neu r:.tliob..l D. Ilivwr+x 140 5. WORKSHOP PERSPECTIVES ...... .................. . RqS.r R~lad.. 143 6. GENERL&L REFERENCES ON STUDIES OF ENVIRONNfE`'TAL TOBriCCO SMOKE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147,

Preface The Second' Workshop on Environmental Tobacco Smoke .ith particulu refennee to efl'eca and espotun levels was held in Geneva, Svitarland, Match 1S•17, 1983. The vorb!top was ortutimd by Ragnar Rylandu M. D, University of GothenbutY. S-edatm and Univcrsity of Geneva. S.riaer- land, toSesher .ith Yvonrte Peterson and Marie-Claie'e Snella. rescarch auii rants and Isabelle Gourdon. It was supported by a grant from the Tobacco Institute, Washit:gton D. C., to the Unirersiry of Geneva. The symbol for the yorlnhop vas dtiigned by Anane Catry:, The participants in the Workshop arc listed' belo.r. Dominnv ?.:, Aviadu I;cal::! :,,;icr,ccr, inr:. 1' 0 Ik,s 307 Siion I Ii11s, Ncw Jersey 070t8 - USA Bjom IIake Dep.rtmenr of Clinical Physiolbgy Sahlgren's Hospital 413 45 Gothenburg - SWEDEN' Anthony M. Cosentino St. \1an'a It'osprtal and Slcdscal f::nrer 450 Stanvan Street San Francj:co. Call£ornra 9a17' - USA Melvin W. First Department of Enrironttuntat Health. Sciences Harvard Univenity. 665 Huntington Avenue Boston. Ma;sachusseta 02115 - USA csula L GAlia Greater Glasgow Health Sorrd West of Scotland Cancer Fttrveillance Unit Ruchil! Hospital Glucov, G20 9NB - SCOTLAND Roger Guillerm Centre d'Erudcs et dc Recherches Techniques sot:+.marines D.C.A.N. 83800 Toulbn Naval - FRIWCE Patrick G. Holt Chmcal lmmunoG6{-y Rc:carch Untt. Pnncess Marg-arco Chfldren's Mctiical Rcscarch Foundationn c/o Pnncess Margaret Hospital for Clii:dren GPOBflx184D Puth, Western Austra:ia - AUSTR.LLIA Honr Hueksuf Freic Univerartat Berlin Untv :nnitskhuikum Steglit: \lctl 1Jtnik und NoLkltnikum Htndenburgclamm 30 1000 Berlin +5 - WEST GERMANY

lfartia J~ Juvir Insntute of Pi• :izius+ Addiiticn Research Unit 101 Denmark Fiill'. London SE5 8lt': - ENGLAND Roger A. Jenkins Bio/Orpnic Anairis Section IAaalroc Chcmiatr7p Division Oa: r1idge Nacional Laboratory PObosX ©ak Ridge. Tennessee 37820 - USA Michael D. LeM-ia Division of Respiratory Sciences The University , of Arizona Health Sciences Center 2 College of Medicine Tuaon. Arimna 8t'24 - USA Cornelius J. Lynch Fraaklin Inttitutc Poticy Analysis Center 1320 Fen.ick Lsne Silver Spring, Maryland 20910: - USA Gtlran Pershagen Nattonal Instrtute of Envtronmcnral Mcdi'- cine Box 60208 104 01 Stockholm - SWEDEN Michacl'..1. H. Russcll !. n~•t. , t i'.. . ._... lUl. Dcnn:arJ< Hill LondomSE.5 SAF - ENGLAND Theodor D. Sterling Simon Fr.acr (;ntvernrn. Departmenr ni Compunng Science; 291r 4`-- Burnabp. Brrrtsh Colombia - CANAD!k VSA 1?,6 llrtnntta Weber Department of Hygteac and Work Phnio- IOU fiTH-Zeatrum 8092 Zdtich - SWTlZEAL.AND Aadtw Zobcr Institute for Oceupational aad Social Mede- dno and Policlinic for Oeeupational Dis- eaaes Uni.enit7 of Erlangen•Nlknbcrg Sehillernr. 25/29, 8520 Erlangen - WEST GER.~tAINY O0.GANIZING COYHIT7LZ Ragnar Rrlander Department of Environmental'. Hvg,ene Univenrtr of Gothenburg P 0 Box 33031 t00 33 Gothcnburg - SVCEDE.t Unr.enrrv oi Goncenbur5 P 0 Box 33031 400 33 Gotnenburg - SWEDEt Jtarre-Clarrc Sncllr Envrronmcnral Medrcrne Unit Institute ior Social and Prevennve \kdicrnc Quar Charlcs-Paigc =' l_UR C;cncva - '-,\R'1TZERL.\\D

3.6. The effect of environmental tobacco smoke in two urban communities in the west of Scotland Csuu.rs R- Gtuas, DAVta ). Hou., VtcroR M. HAwr»ottNS ANa Pgran Bons tJlT10D1rt:770N 'I1u quation of whether environmental tobacco smoke (ETS) an damage bulth has not yet been clearly antvered. It is known that a lighted cigarette emits more tideatrc.m smoke than mainstream and that the smoke ara?lab1e for involuntary inhalation contains substantial amounts of carbon mono:idc, tat, nicotine, benro(a)pyrene and other arci- nogens, and oaides of mttogen ( l). Studiea from )apan (2) and' Greece (3) have suggested that non-smoking wives of heavy, smokers ha•e a t-o-fold incrwed risk of lung cancer when :arnrt.d with non-amoking .ives of non-amokera. In contrast, analysis of dara frorn the prvapectire study of the Ame- riean Cincet Society voiunteas (4) has sug- gested' that vay little, if any, inctrased risk of lung cancer e:isa.hen non-smoking.omen martied' to aawking husbands and oon- amokas married'to non-smoking husbands arr eoetpared The prssentatudy has been carried out in a defined population group in an area of high incidence (5) of lung cancer with a precisely defi,acd population It reports lung cancer data on both males and femalrs. YATR7tLUt AKD ttttTMODa The study compriaes 16,171 apparently healthy individuals aged between 45 and 64, resident in Renfrew and Pairley, two urban areaa in the West of Scotland. They took pan in s multi- phaaie screening survey for ardiorapituory disease between 1972 and 1976. Thit sepre- aenteJ a response nte of 8016 of thou ran- domiy sampled from the resident:population. Details ot this survey have been descri'xd by VMH (6). Information on each rt:apondent's smoking habits an&their experience of tymp- toms of respiratory and cardiovascular disease were collected using a self-completed ques- tionnaire, carefully checked at the time of attendance at the screening unit. The diagnosis of cancer in each individual has been checked in the West of Scotland Cancer Registry and follow up for mortality e.rried out by record linkige (7).ith data from the Registrar General for Scotland. Follow up in complete until 31 December 1982. As members ofthe same household attended the iereening unit, it was possible to identify smoking and non.smoking p.rtnen of amokers nd non-smokers. These were allocated tv categories defined' so as to represent an increasing measure of tobacco exposure. NOTICE ?Alt meterlslimy be Ofotected by copyright Uw (Titlk 17 U S. CoJe).

122 TABCE' 1. M.d.• w[P"*^'+1' e1+bwAbb°Y4°J. Nar.• .f :Zrl..b or.Liq .+wa - 16,17f N..i. s.de fRIOrafiipr rr..~' - 8, 128 (a-.wiin eml.lil) , Male Feas.lc N K N K CoeuoL $17 ' 127 52.3 12.9. ETS eaf~o.utc 310 7.6 1394 34.3 Smokinj 1395 34.3 3W 7.6 Smokin~ + ETS e:posure 1645 43.4 1834 45.2 Tan1 4067 100 4061' 100 TABLE 2 ~y. a..l.,firln.w..f.dt^rrr*rI r.rP'^M7 +rPr"° jJ a.aqs. Aw rwa .J.tl.:rr ed jrwj. Afak Snaol6ng lkspieaor7, ETS T $IS "MPtom f.ontrob etpotuts Smoking espoante 1n[ecrod spit 3.3 4.2 11.1 123 Peaiatent apit M1 14.5' 33.9 35.6 Dtspeon 7.4 11.9• 14.0 1i5.4 Hypcraeetecion 7.2 11.9 • 20.6 21.6 Number of individuals 517 310 1395 1145 •P walue < 0.05 fot eompariaon of eontrol and E'ZS eaposure group. TABLE 3. Aj. +r.+lrludPn..l.'^ fnf^Pwr"!'ep.nrn,7 ryrptwn Ij nrrj..). hr av.f.M.vtlis .d jr.itp: F.a.fu Smoking Ilespintory ETS + ETS arrnptom Cenrrols upoaure Smokins eapoaure Infcncd Mpit 2.1 2! 10.0 9.1, Persiatcnr apn 6.3 7.2 23.9 23.1 Dyapnoes 9.7 14.7.. 16.2 1111.3 HTpenecrenon 3:9 4.! 1'7.u 1':1 Nurnbcr of ibdiridualt 52.3 1394 310: 1534 •• P value < 0.01 for companaon oi contro4 and E'S exposure group !V ~~ ~ rw`I W~ l V' N t'J CJ~ '

123 1. Contrvl-an indi.idual! who does not t+tnoke and who lives ar the urne addrw u another indiridual who does not smoka 2 E'I5 esposed-an individual who does not tmobc but who lives at the nrne addtev as another inZ -idual who does smoke. 3. Smokrs-an individual .ho is a smoker or who has gi.en up smoking up to five years ago but who lives a the same addreas aa an lrsdividual who d'oa nox unoke. . 4.. Smoker and Sl5 espoaed-an indi'vid'ua, who b or.ho has beea a amoker up to five yeus ago and.ho flrea at the same addrest as an individual who also smokes. All individuals in these categories were aged 45-64 at the ti ne of the vsrvey. Es-tmoksrs who had given up smoking for five years or more have been excluded from this analysis. alsvl.T1 The oumber of' males and females in each of the ategories defined above is shown in Table 1., 97:6 % of the pairings were male/female partnen}iips: The prevalence of sel[ reponed respiratory symptoms (6)' found at the survey is shown for each category for males in Tab1e 2 and for females in Table 3. por each meuuri, infeeted apic, persistent spit, drspnoea and hfperaem- tion an increasing dose response trJarjoaship .ra evident in males. Ti.c prevakrut of thcae four symptoms .u slightly higher in the eapoaed to ETS thin in the eorttrol.. This observuion was eonaiatent in both malea and ferrulea. The pee.alence of eardiovaaeular symptoms found at the time of the surve7 ia shown in Tabk 4. In females angina and ECG abnorma- litiet (6) were slightly more eommon in the patp exposed to ETS tlun in the oontrola, althouQft the magnitude of the differenots.u small. The rnetx trend tu shown for rAales. litale mort.lit7 for the different eatesories is shown in Table S. A doae.rssporue relation- •hip was found for lung cancer rising froam a rats of 4 per 10,000 for the control ptwp to 13 per 10,000 for the group exposed to ETS to 22 per 10,000 for the smoking group and 24 per 10,000 for the smoking group also erzpoaed to ETS. The rates for other smoking related cancers and for smoking related diseases (8) did' not show a difference between the control and groups exposed to ET5 except for the rate for myocardial infarction (1CD410) which was TASLE 4. AV uoL~L)d pnrL.n .Jr.rtLwrrealn t~enra.r tP nrj.r). Pn nwt.f.fl.vli..r6j.rn'P Cardiova.cular .qmptom Controls ETS escpaure Snwking Smokint t ETS eapo.urs A6kr: AnZina 6.6 6.4 9.6 12.3 Mapr ECG abnormaliry 1.4 1.3 2.0 T2 Fm"4r ~ An`ina 4.2 SJ 5.4 6.L Mpoi ECG abnorrnalirr 0.4 0.6 0.6 as

124 TASIE S. .t....r 4V .a.d.df.r ....i y nr r. 10.ooa 8j ...iis ..q.~i Ya. cNra mt dasat5 coatnb S1S espo.ntt Smotdns /lJl oaae 91 t0 156 L..g a 4(2) 13(4) 2Zn0): OeSat Q 12(6) 6(7) !4(Sq AQ (110) 31(16) IS(]4) 60(84) D[D (411r1) 4(2) 0(0) 11(13) CVD 10(S) 3(1) t2(17) Odten 31(16) 23(7) 27(38) Sawking telatcd 75(39) 77(24) 140(19S)' Non-amok)ng rslated 16(8) 13(4) 17(23) Total' numbcr of dcatln 47 28 218 06 2s(44) 22(41) 16(K 14(23) 16(29) 3S(64) 1.U(24T) 22(40) W Fyuro in parsnthsaia us thc numben of deaths TABLE 6. Amad qr q.aLnlii.J'awr.Gtj nue prr I0,000 `j nw4ia1 wrm fiarler Cauac oi PTS Snwlung + ET3 dcatlia Controls e=posurc Smoking t=poaute All i eau.a 40 Lung Ca 4(2) Othcr Ca 1A(J0) 141(410) 4(2) 1HD (411-4). 0(0) CVD 2(1) C'thcra 12(6) $rnokin8 rclated IS(8) Non-arnoking rel.ted 23(12) Total,number of deaths 21 S8 4(6) 24(33), 12(17) 1(2) 4(5) 13(18) 30(42) 27(37) 1111 67 7(2) 26(8) 19(6) 3(1) 7(2) 26(8) SS(17) 36(11) 27 77 6(11') 22(40) 21(39) 2(4) 9(16) 17(31) S2(96) 24(44) 141 Fi=urta in parentAesia ara the numbcn of deaths TABLE 7: rrmm.8r oa.iiq i!' w.n+ RB- /.. !.j gT$ Senoking + ET5 Controla ta.poaure Smoking exposure Jtalb 0 0 41.8 57.3 Fenulea 0 0 46.5 53.4

125 slightly higher in the group exposed to EZ5 than in the controls. Femalc mortality is shown in Table 6. All causes mortalitf, is higher in the group exposed to ET5 than in the eontroli. This was nat the case for lung cancer although mortality from myoeatdi.J infarction .•as higher in the group atpoaed to ETS when compared with the eon- txols. Division ef all diseascs into those considered' smoking and' non•smoking related (8) pro- duced a higher rare in the group exposed to ETS .nhen compared with controls. On account of the app.rently unusual rel.- tionahip between lung cancer risk and tobacco consumption in the West of Scotland'. (9) ~ the amount smoked by individuals in the defined categories is shown in Table 7: In the smoking group also exposed to ETS 57.3 % of males and 53.4 % of females smoked more than 15 eiga- rettes pv day. This compares with 4 1.8 1ti of miles and 46.5 % of females in the smoking Foup• DUCSJIt1oN. Insufficicnt time has elapsed since the eomple- tion of the recruitment phase of this study (1976) for sufficient numbers, either of inci- dent eases of cancer or of other diseases, to allow fum conclusions to be based on the tesuhs. The results have been esprasaed as annual age nandardiaed rates per 10.000, as the anoken for five years or morc .ere also es<luded from the analysis. Aa there is still doubt whether these groups aocount for the total'diaerepanry, given an initial response rare of 80 %, the authors require to continue their investigaion of this apparent diserepancy. This study hu unique features.•hich allov even preliminary tesults to be of interest. Theac are: 1. The study has been carried out in an area with the highest national incidence rate of lung cancer recorded (S} 2 It is a prospective cohort study carried out in a geographically defined population vhoac membera are homogeneous by social class and ethnic group. 3. Other reports (2, 3, 4) concentrate on (emales. This study includes both sexes. 4. No questions eoncerning e:poture to ET5 rers asked, thus avoiding the biaa inhaertt ln self-reported' aaaesaments of partnership d"aR Given the strength of the epidcsnlological association bStreen cigarette amoking and lung tancer, It ia this dlseaac rather thart ischaemic heart diaease that would be first to appear in excess in the cohort if a d'oae response relationship e:isted, especially as the tsspon- dents.cere all apparently healthy at the time of screening. _ In maks, the easa of lung txnev occurring Snon-atttokea were found tmee &eqtsently in total number of incident cases and the number espoaed to ETS (4/310)Aaa in the eon- ' of deaths is small in the control and ETS expo- Pttohz !2/S 17) (Table 5). No dose-rssponse rela- sure groups (Tables S, 6). tionship was apparent in kmales for lung The rcaults relate to onlr 8,128 of the 16,171 cancer deaths though an effect was present individuals who attended the multi-phasie screening unit (50 %). Some of this discrepaney can be accounted for by those living alone. those living with a partner outvitli the age nng+o, and those living with a partner.ho has not attended Thou who have been ea- .hen all smoking rdatcd (8) deaths including deaths from myotardial infarction were taken into account (faL/e 6). These findings may be aupported' to an extent br the dose-responsc relstionship than eaisr• for self-reportcd respintory symptoms ?Q 0' N Gi Cj OD N N N CD