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k'. i i 265 passive smokers are exposed is of the order of 10% of that of active smokers. Matsukura et al. (1984) have suggested that such high levels of uptake in passive smokers may be seen in Japan. If there were independent evidence that nonsmokers exposed to other peo- ple's cigarette smoke do not'. differ on known~ risk factors for CHD from unexposed nonsmokers; more reliance could be placed on Hirayama's results. Svendsen et al. (1985) reported on the effect of cigarette smoke exposure to smoking wives among men participating in the Multi- ple Risk Factor Intervention Trial (MRFIT). MRFIT, which began in the mid-1970s, was a randomized primary prevention trial de- signed to test the effect of a multifactor intervention program on mortality from coronary heart disease in men with previous car- diac episodes. The men were chosen for participation if they had at least two of three risk factors for heart disease, including smoking, high cholesterol levels, or high~ blbod pressure. The results re- ported' by Svendsen et al. (1985)', based on the group of inen who never smoked but whose wives may or may not have been smokers, indicate no difference between exposed (i.e., smoking wives) and nonexposed (i.e., nonsmoking wives)' of nonsmoking men for blood pressure or serum cholesterol. The MRFIT study demonstrates a ~ roughly twofold increase in the risk of CHD mortality and morbid. ~ ity among nonsmokers exposed'to ETS. The sample size was small, an& the results were not'statistically significant. Adjustment for 3 other risk factors for CHD did not change the estimates of effect. ; SUMMARY AND R.ECOMMENDATIONS What Is Known 1. No statistically significant effects of ETS exposure on heart rate or blood pressure were found in healthy men, women, and school-aged children during resting conditions. During exercise there is no difference in the cardiovascular changes for men and women between conditions of exposure to ETS and control condi- tions. 2. With respect to chronic cardiovascular morbidity and mor- tality; although biologically plausible, there is no evidence of sta- tistically significant effects due to ETS exposure, apart from the study by Hirayama in Japan.

268 What Scientific Information Is Missing 1. Experimental studies with animal models need to be per- formed with ETS to determine whether the cardiovascular changes seen following exposure to whole smoke also occur following expo- sure to ETS. 2. Existing studies have not provided' evidence of serious harm in people with heart disease. With regard to angina onset, the findings are uncertain~ and need to be repeated. REFER.EIN'CES Anderson, G., and T. Dalhamn. Health risks due to passive smoking (in Swedish)! L"akartidningen 70t2833-2836, 1973. Anderson, E.W., R.J. Andelman, J.M, Strauch, N.J. Fortuin, and J.H. Knelson. Effect of Iow-level carbon monoxide exposure on onset and duration of angina pectorus. Ann. Intern, Med. 79:46-50, 1973. Aronow, W.S. Effect of passive smoking on angina pectoris. N. EngL J. Med. 299:21-24, 1978. Aronow,, W.S. Aggravation of angina pectoris by two percent carboxyhe- moglobin. Am. Heart. J. 101:,154=157, 1981. Aronow„ W.S., and M,W. Ibbell. Carbon monoxide effect on exercise-induced angina pectoria. Ann. Intern. Med. 79:392-395, 19731 Aronow,, W.S:, J. Cassidy, J.S. Vangrow, H'. March, J.C. Kern, J.R. Gold- smith, M, Khemka, J. Pagano and M. Vawter. Effect of cigarettee smosking and breathing carbon monoxide on cardiovascular hemody- namics on anginal patients. Circulation 50:340-347, 1974. Aronow„ W.S., R. Charter,, and G. Seacat. Effect of 4°.b' carboxyhemoglobin on human performance in cardiac patients. Prev. Med. 8:562-566,,1979. Astrup, P., and K. Kjeldsen. Model' studies linking carbon monoxide and/or nicotine to arteriosclerosis and cardiovascular disease. Prev. Med. 8:295- 302, 1979. Bridge, D.P.,, and M. Corn. Contribution to the assessment: of nonsmokers to air pollution from cigarette and cigar smoke in occupied spaces. Environ. Rea. 5:192-209i 1972. Dahms, T.E. J.F: Bolin, an& R.G. Slavin. Passive smoking: Effects on bronchial asthma. Chest 80t530-534, 1981. DeLucia, AJ., J.H. Whitaker, and L.R. Byrant. Effects of combined ex- posure to ozone and carbon monoxide (CO) in humans„ pp. 145-159.. In S.D. Lee,, M,G. Must'afa, and M,A. Ivtehiman, Eds. Advances in Modern Environmental Toxicology, Voll V. International Symposium on the Biomedical Effects of Ozone and' Related~ Photochemicall Oxidants. Princeton, New Jersey: Princeton Scientific Publishern,,1983. Drinkwater„B.L., P.B. Raven„S.M~ Horvath, J.A. Gliner„R.O. Ruhling, and N. W. Bolduan,, and S: Taguchi. Air pollution„ exercise and heat stress. Arch. Environ. Health~ 28:277-282, 1974. Harll Hira4 Hucl Hug, II i Hurt J azvj ~ Lawl LigN Liu, Luq M'atl Mcd Pim1

i 267, I (in k.H. knd' I led. jhe- i lced ' Id- tt'e dy- bin 79. /t[95r i ,kers ices. ~ on I,ex- 6 in ~ on mts. fess ~ Environmental Protection Agency. Rev:ued: Evaluation of Health Effects Associated' with Carbon Monoxide Exposure:, An Addendum to the 1979 EPA Air Quality Criteria Document for Carbon Monoxide. PubL No. EPA-600/8-83-033F. Washington~ D.C.: U!S. Government Printing Office, 1984. Foliart, D., N.L. Benowits, and C.E. Becker. Passive absorption of nicotine in airline flight attendants. N. Engli J. Med. 308:1105, 1982. Garland, C., E. $arrett-Connor, L. Suarez, M. Criqui, an& D: Wingard. Effects of passive smoking on ischemic heart disease mortality, of non- smokers. Am. J. Epidemiol. 121:645-650, 1985. Gillis, C.R., D.J. Hole, V.M. Hawthorne, and P. Boyle. The effect of environmental tobacco smoke in two urban communities in the west of Scotland. Eiir. J. Respir. Dis. 65(S133);121-126,,1984. Harke, H.-P. Zum Problem des `Passiv-Rauchens.' Munch Med Wochenschr. 51:2328-2334„1970. Harke, H.-P., and'A. Bleichert. Zum Problem des Passivrauchens. Int, Arch. Arbeitsmed'. 29:3T2-322„ 1972. Hirayama, T. Lung cancer in Japan: Effects of nutrition and passive smoking, pp. 175-I95. In M. Misell and P. Correa Eds. Lung Cancer: Causes and Prevention. New, York: Verlag Chemie, Iaternational„ Inc., 1984. Huchy, R., J. Danko, L. Spatling, and R. Huch. Risks the passive smoker runs. Lancet 2:1376, 19801 Hugod, C.,, L.H. Hawkins, and P. Astrup. Exposure of passive smokers to tobacco smoke constituents. lat. Arch. Occup. Environ. Health 42:21-29, 1978. Hurshman, L.G., B.S. Brown, and R.G. Guyton. The implications of sid'estream cigarette smoke for cardiovascular health. J'. Environ. Health 41:145-149, 1978. Jarvis, M.J., M.A.H. Russell, and C. Feyerabend. Absorption of nicotine and carbon monoxide from passive smoking under natural conditions of exposure. Thorax 38:829-833, 1983. Lawther, P.J., an& B,T. Commins. Cigarette smoking and exposure to carbon monoxide. Ann. N.Y. Acad. Sci. 174:135-147, 1970. Lightfoot, N.F. Chronic carbon monoxide exposure. Proc. R. Soc. Med'. 65:798-799, 1972. Liu,, L.B.,, C.B. Taylor, S.K. Peng, and B. Mikkelson. Experimental' arte- riosclerosis in Rhesus monkeys induced by multiple risk factors: Choles- terol, vitamin D and nicotine. Arterial Wall 5:25-38, 1979. Luquette, A.J., C.W. Landess, and D.J. Merki. Some immediate effects of a smoking environment on children of elementary school age. J. Sch. Health 40:533-535, 1970. Matsukura,,S., T. Taminato, N. Kitano, Y. Seino, H. Hamada,,M. Uchihashi, H. Nakajima, and Y. Hirata. Effects of environmental tobacco smoke on urinary cotinine excretion in nonsmokers: Evidence for passive smoking. N. Engl. J. Med. 311:828-832, 1984. McGill, H.C: Jr. Potential mechanisms for the augmentation of atheroscle- rosis and astherosclerotic disease by cigarette smoking. Prev. Med. 8:390-403, 1979. Pimm; P.E., F. Si{vermany and R.J. Shephard. Physiological effect's of acute passive exposure to cigarette smoke. Arch. Environ. Health 33t201-223,. 1978.

Polak, E. Le papier a cigarette. Son role dans la pollution des lieux habites. Tabagisme passif: Notion nouvellee precise. Brux. Med. 57:335-3d0, I ~ 1`,lr1. Raveny P.B., B.L. Drinkwater, RO. Ruhling, N.W. Bolduan, S: Taguchi, 1 Gliner, and S,IvI. Horvath. Effect of carbon monoxide and peroxyacetyl nitrate on man's maximal aerobic capacity. J. App1. Physiol. 36:288-293, 1974a. Raven, P.B., B.L. Drinkwater, S.M. Horvath, RO. Ruhling, J.A. Gliner, J.C. Sutton, and N.W. Bolduan. Age, smoking habits, heat stress, and their interactive effects with earbon monoxide and peroxyacetylhitrate on man's aerobic power. Int. J. Brometeor. 18:222-232, I974b. Rummel,, RM., M. Crawford, and P. Bruce. The physiological' effects of inhaling exhale& cigarette smoke in relation to attitude of the nonsmoker. J. Sch. Health 45:524-529; 1975. Russell, M.A.H_„ P.V. Cole, and E. Brown. Absorption by nonsmokers of carbon monoxide from room air polluted by tobacco smoke. Lancet 1:576-579, 1973. Schievelbein, H.,, and F. Richter. The influence of passive smoking on the card'lovascular system. Prev. Med. 13:626-644, 1984. ' t~ Schievelbein, H.,, V. Londong, W. London¢, H. Grumbach, V. Remplik, A. °-~---- --~ ~, ,--'-~ '."- -'- --"-- '- , ..,.r ................ contribution to the influence of nieotine on fat metabolism. Z. Klin~ ~ ~ Chem, Klin. Biochem, 8:190-196„ 1970. g~ Seppanen„A., and A.J. Uusitalo., Carboxyhemoglobin saturation in relation n to smoking and various occupational conditions. Ann. Clin. Res. 9:261- 268,19T7. Shephard, R.J., R. Collins, and F. Silverman. `Passive' exposure of asth- matic subjects to cigarette smoke. Environ. Res. 20:392-402, 1979a. Shephard, R.J., R. Collins, and F. Silverman. Responses of exercising subjects to acute 'passive' cigarette smoke exposure. Environ, Res. 19:279-291, 1979b. Srch M. On the significance of carbon monoxide in cigarette smoking in an automobile. Dtsch. Z. Gesamte. Gerichtl. 60:80-89, 1967.. Svendsen, K.H., L.H. Kuller, and J.D. Neaton. Effects of passive smoking in the Multiple Risk Factor Intervention Trial (iMRFIT). AHA Circ. Monogr. 114(Suppl:):III-53, 1985. (Abstract 210) U.S, Public Health Service. The Health Consequences of Smoking: Car- I d diovasculi<r Disease. A Report of the Surgeon General. DHHS(PHS) Publ 'No 84-50204 W h' D C• U S D rt t f H lth d , as ington, ... ., epa men o ea an Human Services, Public Health Service, Office on Smoking and Health„ ~ 1983. 384 pp, n Wald, N.J., M~ Idle, J. Boreham, and A. Bailey: Carbon monoxide in hi+' breath in relation to smoking and carboxyhemoglobin levels. Thorax rhll 3fi~7Fifi.3fi9~ IURI_. in S in