Tobacco Documents Online

JULY23; 11993 [I17] CDC Launches New Antismoking Campaign According to a press report, a new anti-smoking advertising,campaign has been devised by the Centers for Disease Control, an& Prevention, (CDC). The ads are apparently targeted toward nonsmokers in the workplace and were unveiled during,a June 23, 1993, meeting of the Interagency Committee on Smoking and Health. Intended for television and other media, the CDC ads reportedly urge employees to tell their bosses they want a smoke-free workplace. See Occupa- tional Health 6' Safety News, July 9, 1993. MEDIA COVERAGE [18] "Invironment: The New Horizon - Indoor Environmental Quality," Consulting Specifying Engineer, J,une 1993 This supplement to the monthly publication took an engineer's look at the effective construction of buildings which address total: indoor environmental qualityin their design. The article used the accommodation of smokers in the workplace as a case study for developing a model. The article included'strategies for accommodating smokers in high-rise, mid-rise, and small office build- ings, which included technology such as displacement ventilation, air filtration technology, air pressure zones, and individual smoking areas. [ 119] "The Great American, Smokeout", CNN' C'rossf re, July 2, 1993 Crossfire hosts Mike Kinsley and Pat Buchanan discussed discrimination against smokers and smoking with, guests Dave Brenton, editor of The American Smoker's Journal, and Dr. Sidney Wolfe, director of Public Citizen's Health Research Group. The lively, yet largely unsubstantial, debate yielded comments that a typical nonsmoker's exposure to ETS amounts to roughly the equivalent of one cigarette a year„and'that airlines are in financial trouble in part because they banned smoking on, planes. [20] "How Secondhand Smoke Hurts Kids," R. IsraeloffS Parents Magazine, August 1993 Citing the EPA Risk Assessment on ETS, this article discusses the purported effects of ETS exposure on 7 young and unborn children. The alleged effects on young children are said to include increased incident of infections, asthma, increased'chance of SIDS and lung cancer. The purported effects of ETS exposure to fetuses are alleged to include low birth weight, dimin- ished llrng function and a diminished milk volume inn the mother. The article goes on to offer some suggestions to lower children's exposure to ETS. The suggestions ranged fromquitting smoking and finding smoke-free day care centers to joining local1ealth and advocacy organiza- tions that fight for the rights of nonsmokers. [211 "Anti-scent Sentiment Catching,on in Offices," S. Rostler, The Plain D'ealer, July 16, 1993 The author of this article discusses the issue of fragrance bans in workplaces and compares them to ETS bans. The ban on fragrances at public meetings in San Francisco is mentioned, and a number of people who are annoyed by perfumes are quotedl regarding their coping,strategies when in the presence of heavy scents in the workplace. A partner in a Cleveland law firm specializing in occupationall safery and health issues observes that there is no easy way for employers to:enforce a ban on scents. SCIENTIFIC/TECHNICAL ITEMS LUNG CANCER [22] "Environmental Tobacco Smoke and Lung Cancer," E.T.H. Fontham, P. Correa, P.A. Buffler, R. Greenberg, P. Reynolds, and A. Wu- Williams, The Cancer Bulletin 4 5(1): 92-94, 1993' [See Appendix A]', This brief article discusses the 1991 Fontham, et al., study of spousal'smokingt ln addition to providing a summary of the design and results of the study, the authors mention potential confounders. They claim t}iat their calculated risk estimates "persisted" after adjustment for vegetable consumption, family history of lung cancer, and employment in "high,-risk"' jobs: They also indicate that they have collected some d'ata, on radon levels, and discount radon as a potential', confounder, as well.

8'. CARDIOVASCULAR ISSUES. [23] "Association of Passive Smoking with Increased Coronary Heart Disease Risk Is Not Explained by Elevation of Leucocyte Count," M.S. Green,. J. Shaham, J. Green, G. Harari, and J. Bernheim, European Journal of Public Health 3: 14-I 7, 1993 [See Appendix A] In this study, conducted in Israel, leucocyte counts are compared in~ smokers, nonsmokers and persons reportedly exposed to ETS. [Leucocytes are a kind of blood cell. Leucocyte count has been reported to be associated with an~ increased risk of coronary heart disease.] The authors report that reportedly ETS- exposed persons had leucocyte counts similar to those of nonsmokers. RESPIRATORY DdSEASES AND CONDITIONS - ADULTS [24]i "Effects of Maternal Smoking and Childhood Respiratory Illness on Pulmonary Function in Young Adults: The CAR.DIA Study," J.E. Dunn, S. Kellie, K. Liu, and J. Keller,,Society for Epidemiological Research, 1993 Annual Meeting, Keystone, Colorado, Abstract No. 306, June 1993 [See Appendix A] According to these authors, a comparison of current lung function data and reports of maternallsmoking and childhood respiratory illness before age ten suggesct that early lung infections and maternal smoking may "affect" adult lung,function: [2'5]' "Passive Smoking and Evolution of Lung Function in Young Adults. An Eight-Year Longitudinal Study," M.S. Jaakkola, J.J.K. Jaakkola, P. Ernst, and M.R. Becklake, American Review ofRespiratoryDisease 147(4 Part 2): A215, 1993 [See Appendix A] In this abstract, the authors report on a study in~ which 117 never smokers were tested for lung function at the start of the study and'. then again after eight ETS/IAQ REPORT, ISSUE 52 years. ETS exposure was reportedly not associated1with "clinically important ventilatory impairment," ass measured by change in lung function over time. [26] "Effets Sanitaires d'une Exposition Chronique a la Fumee de Tabac sur une Population de Non Fumeurs (Health Effects of Chronic Exposure to Tobacco Smoke on a Non-Smoker Population)" [English abstract only] ` A.M. Laurent, A. Bevan, N. Chakroun, Y. Courtois, B. Valois, M. Roussel, B. Festy, and S. Pretet, Rev. PneumoL Clin. 48: 65-70, 1993 [See Appendix A] In this study, conducted in~a prisons 14 nonsmokers lived for one month in a cell'with three smokers. At the end of the study, there were reportedly no differences in measurements of lung function, expired carbon monox- ide, cotinine, or other possible indicators of exposure. RESPIRATORY DISEASES AND CONDITIONS - CHILDREN [27] "Privilege and Health - What Is the Connec- tion?" Ms Angell, New EnglundJournal ofl['ledi- crne 329(2): 126-127; 1993 [See Appendix A], This editorial focuses on the correlation between~ socioeconomic status (usually measured using income„ education~andJor profession) and'health endpoints. The author uses childhood asthma an& "passive smoking' as an example of the need'to consider socioeco- nomic status in interpreting a reported ~ association. [28] "Is Passive Smoking a Cause of Asthma in Childhood.>"' R. Ehrlich, M. Kattan, and D.E. Lilienfeld, Journal of Smoking=Related Disorders 4(2): 91-99, 1993 [See Appendix A] Available studies investigating parental smoking and childhood asthma or lower respiratory conditions (e.g., wheezing) are reviewed in this paper. The authors acknowledge inconsistencies among the studies, and indicate that further questions remain. Nevertheless, in their opinion, a causal'relationship between maternal smoking and childhood asthma is supported by the available data. (

JULY 23, 1993 ETS E?tiPOSURE AND MONITORING [29] "Measuring Exposure to Environmental To- bacco Smoke in Studies of Acute Health Ef- fects," M.C. Marbury, S.K. Hammond, and N.J. Haley, American Journal ofEpiderrriology 137(10); 1089-1097, 1993 [See Appendix A] This paper reports on a study comparing question- naires, ambient nicotine measurements, and urinary cotinine measurements as methods for characterizing ETS exposure in a population of 48 children under the age of two. The authors report that, ambient nicotine measurements and urinary cotinine measurements provided better data than, did questionnaires, but thatt the two rneasures were so closely correlated as to be redund'ant. As ambient nicotine measurements were more easily obtained, the authors suggest that theywilly use that, method in their future work. INDOOR' AIR QUALITY [30] "Indoor Air: Potential Health Risks Related to. Residential Wood Smoke, as Determined Under the Assumptions of the US EPA Risk Assess- rnent IVlodel, " K.S. Sidhu, J.L. Hesse,,and A W. Bloomer, Indoor Environment 2: 92-97, 1993 [See Appendix A] I The authors of this paper apply EPA methodology too generate risk estimates for components of wood smoke, and'project excess cancer cases of 0 to 5 in a population of 100,000 for formaldehyde and 0 to 10 in a popula- tion of 100 million for polycydic aromatic hydrocar- bons. They suggest that exposure to wood smoke "should be recognivxd as a potentially significant health risk factor,"'especially for "sensitive populations," i.e., children, asthmatics and persons with heart disease. [31] "A Prevalence Study of the Sick Building, Syndrome (SBS) and' Facial Skin Symptoms in Office Workers," B. Stenberg, K.H. Mild, M. Sandstrom, J. Sundell, and S. Wali, Indoor Arr 3: 71-81, 1993 [See Appendix A] In this paper, Swedish researchers report on a selected set of data collected in a study of nearNy 5,000 office workers. They report that female gender, asthma/ rhinitis, paperwork, and work with VDTs were related with an increased prevalence of sick building symp- toms in their study population. They also report a relationship between perception of health and percep- tion of indoor climate in their sample. [32] "Volatile Organic Compounds in Ventilating Air in Buildings at Different Sampling Points in the Buildings and Their Relationship with the Prevalence of Occupant Symptoms," J. Sund'ell'', B. Andersson, K. Andersson, and T. Lindvall, Indoor Air 3':' 82-93, 1993 [See Appendix A] The authors of this Swedish study report that occu- pant reports of symptoms were associated with elevated formaldehyde levels and with a decrease in total VOC levels between supply air and room air. They termed the latter °`lost' TVOC," and suggested it could be related to chemical transformations of the substances. IN EUROPE & AROUND THE WORLD REGULATORY AND ~~ LEGIiSLATIVE. MATTERS EUROPEAN PARIi.IAh1ENT [33] Briefing Paper on "Passive Smoking" Released OniJune 22, 1993, the Directorate General for Research of the European Parliament released a briefing paper entitled "Smoking Tobacco andl Health: Passi've Smoking," The paper provides an overview of governmental studies on ETS, including the EPA Risk Assessment on ETS, to support its position that "[t]he inhalation of other people's tobacco smoke has become recognised as a serious health hazard." In a cursory fashion, the paper links ETS exposure to lung cancer; irritationlof eyes, nose, throat and lower respiratory tract and adult asthma; lieartdisease; exacerbation of ~ sick building syndrome; and diseases in children such Q as bronchitis, pneumonia, reduced lung function, glue N ear, asthma, wheezing, low birth weight and cot deaths. eip] %I The bulk of the document focuses upon legal issues. ,~ Strengths and weaknesses of ETS products liability ~ cases are noted. Among the weaknesses discussed are w rZ ~

lo causatiom problems, lack of knowledge by the tobacco industry about alleged risks prior to the early 1980s, and intervening causation, i.e., smokers might not have heeded a warning about purported dangers of ETS exposure even if the tobacco companies had given it. Cases against the industry and employers all over the world are discussed, including TIA'v: AFCO, Broin, Butler, Veronica Bl'and, and Liesel Scholem. Richard: Daynard of the Tobacco Products Liability Project is cited as a source of information regarding cases in the United States in which nonsmokers have recovered benefits or~ damages on the basis of a variety of legall theories. The paper concludes with a discussion of the granting of legal aidlin the United Kingdom for a woman who is planning,to sue her boss for injuries allegedly suffered as a result of ETS exposure. "The granting of legal aid in this case may show the direction in whicl't the climate of opinion is moving," the paper states. GERMhNY [34] Railway System Places Further Restrictions on. Smoking According to a press report„the Bundesbahn is planning to restrict smoking to seats in the smoking area of train carriages. Previously, smoking was also permitted in side aisles and entrances. The Ministry of Transport reportedly announced that the change would take place sometime this year. See Die Tabak Zeitung, It fay 21, 1993. LEGAL ISSUES AND DEVELOPMENTS AUSTRALIA [35] Former Spouses Seek Injunctions to Stop Smoking in Front of Children According to a press report, applications have been. filed in Adelaide andMelbourne to stop former spouses from smoking in front of their children. The cases are believed to be the first of their kind in Austra- lia and are expected to be heard later this month in Family Law Court. See Canberra Times, Australian, Age, West Australian, Advertrser, and CourierMai4 July 7, 1993. ETS/IAQ REPORT, ISSUE 52 [36] Employers Advised to Make Premises Smoke Free Partners in the personal' injury insurance division of Phillips Fox have reportedly advised employers to ban smoking in~ the workplace. "Employers must ensure that their premises become smoke-free or they face criminal'and'civil litigation," state partners John Boland and Norman Abrams. They apparently regard information about the alleged health effects of ETS as "unequivocal medical and scientific evidence." SeeAge, July 13, 1993. OTHER DEVELOPMENTS FRANCE [37] Booklet Counters Misrepresentations About Smoking Bans The Tobacco Documentation ~ and Dnformationi Centre in Paris has issued a booklet entitled "What One Hears About Tobacco" to correct misrepresenta- tions that have been made about public smoking banss in France and the European Community. Among those issues discussed are the claims tharo smoking is regulated in public places everywhere in Europe and that ETS endangers the health of nonsmokers. French legislation on smoking,in public places is reprinted ini the booklet. N ETHE RLAN DS [38] Amsterdam Airport to Impose Smoking Restrictions In 1994, Amsterdam's Schipholiwilllreportedly become the first airport in Europe to impose signifi- cant restrictions,on smoking. Wiil'a the exception of a few designated smoking,areas, smoking will not be permitted in the departure and arrival halls and at the luggage carousels. The restrictions will apparently cost millions of guilders as ashtrays willl need to be replaced with rubbish bins and no smoking signs. SeeAlgemeen Dagblacr; May 28; 1993'. (

JULY 23, 1993 UNITED: KINGDOM~ [39] Employees Forbidden from~ Smoking When in Uniform The Pembrokeshire NHS Trust in West Wales has reportedly banned smoking for workers at anytime that they are in uniform, including,whileomor offd'uty. Apparently,, those wishing to smoke on the way to or from work must change out of uniform to do so. The policy is believed to be the first of its kind in the country. According to a health workers union official, the policy goes too far. °°We fully support no smoking in hospitals and health centers,"'he reportedly said, "but what employees do when they are off duty is up to them."' See Today, Juiy2, 1993. [40] Smoking in Restaurants Leaflet Produced The Restaurateurs Association of Great Britain hass produced a leaflet entitled Smoking in Restaurants for distribution throughout the leisure industry. The leaflet, which was produced in conjunction with~the Tobacco Advisory Council„provielespractical sugges- tions for accommodating smokers and nonsmokers in the same restaurant. [;41] Bare Majority Favors Restaurant Smoking Bans According to a survey conducted by MORI for the Health Education Authority, some 51 percent of respondents reportedly think smoking should be banned in restaurants. Forty-five percent of those surveyed said there should be designated'smoking areas, and three percent said customers should be free to smoke wherever they wisht The survey was appar- ently conducted last year, but the results have yet to be published. According to a press report, the findings contrast with current practice, as a large majority of restaurants permit patrons to smoke when and where they wish. See The Times, July 17, 1993. 11

JULY'23, 1993 APPENDIX A The numbersassignedlto the following article summaries correspond with the numbers assigned to the synopses of the articles in the text of this Report. LUNG CANCER' [22] "Environmental Tobacco Smoke and Lung Cancer," E.T.H. Fontham, P. Correa, PA. Buffler, R Greenberg, P. Reynolds„and A. Wu-Williams,. The Cancer Bulletin 45 (1): 92-94, 1993 "In late 1985, a multicenter US study was initiated to evaluate the association! of ETS with the risk of lung cancer in: nonsmoking females. The study was designed to minimize some of the method'ologi,c problems that have been:discussed in review[s]'! of ETS lung cancer studies by the National Research Council and the International Agency for Cancer Research, among others. These induded misdassification of smoking status, inaccuracy of case diagnosis and cell type, recall bias, ETS exposure from sources in addition to the spouse, and' inadequate control of potential confounders. The fmdings of the first 3' years of this study are summarized' here."' "The estimated risk of lung,cancer in nonsmoking women that is associated with living with a spouse who smoked'was approximately 30%, regardless of which control group was used in the comparison. An increase in the risk of approximately 50%; was observed for adenocarcinoma of the lung compared to each control group. Separate analyses were conducted for subjects who personally responded and for those whose infor- mation was obtained from surrogate respondents. The findings were consistent for self- and proxy-respon- dents. All odds ratios were adjusted for age, race, geographic region,, respondent type, income, and education. An ~ approximate 30% risk of lung cancer associated with spousal ETS exposure persisted'~ after an additional adjustment was made for the consumption~ of vegetables (the most significant food or nutrient factor),, family history of lung cancer, and employment in high-risk occupations or industries. Household radon levels were determined in a sample of case and control' homes under separate funding. Radon levels are quite low in all of the areas included in our study: <1% of all homes tested had levels of>_4 pCilL. The ob- served' increased risk of lung,cancer associated! with A-I ETS exposures is unlikely to result from confoundingg by radon, diet, or other such factors." "The findings of this study- which included methods to evaluate recall bias, minimize misclassification of smokers as nonsmokers, ensure accuracy of diagnosis and classification of lung cancer, and adjust risk estimates for potential confounders - are consistent with and' extend the findings of numerous published reports that did not address all of these issues: The overall 30% increased~ riskk associated with ETS exposurefrom a smoking,spouse is remarkably close to the 25% to 34% estimates of the evaluation of relevant studies in the 1986 report of the National Research Council. Thesignifieano positive dose response to exposure to tobacco smoke within households, in occupational settings, and in social settings d'uring adult life strongly supports an etiologic role of ETS in lung cancer in nonsmokers and extends the findings from the home into the workplace and'public settings."' CARDIOVASCUT AR ISSUES [23] "Association of Passive Smoking with Increased Coronary Heart Disease Risk Is 23Not Explained by Elevation of Leucocyte Count," M.S. Green, J. Shaham, J. Green, G. Harari,. and J. Bernheim,. European Journal ofPublic Health 3: 14-17, 1993 "The increased risk of coronary hean; disease in cigarette smokers may be due at least partly to an elevation~of the leucocyte count. Chronic passive smoking has also been found to be associated with an increased risk of coronary heart disease, but its effect on the leucocyte count has not been reported. in this study 250 male factory empl'oyees aged 20-64 years were interviewed on smoking behaviour an& exposure to environmental tobacco smoke, and blood counts were determined. Urinary cotinine was measured by radio-immunoassay and corrected for urinary creati~ nine concentrations. Mean leucocyte count was significantly higher among smokerstompared with nonsmokers. On the basis of smoking history, passive smokers had leucocyte counts similar to non-smokers." "The aim of this study was to compare the leucocyte count in~cigarette smokers with that of non-smokers exposed to varying concentrations of environmental tobacco smoke. Utinary cotinine concentrations were used'to determine the extent of exposure to environ- mentalltobacco smoke."

A-2 "These findings demonstrate that leucocyte count is not significantly elevated in non-smokers exposed to different levels of environmental tobacco smoke. In, addition, among light smokers there was no increase in leucocyte count. This suggests that if in fact elevation of the leucocyte count contributes to the risk of coronary heart disease in smokers, this is not likely to be the mechanism for passive smokers or indeed for light smokers. In general the mechanism for the increased risk of coronary heart disease in passive smokers is not well understood. It has been postulated'that it may be due to effects on blood factors such as platelet aggrega- tion or through a role of the d'amaging,and muragenic effects of agents such as the polycyclic aromatic hydro- carbons on the endothelial and smooth muscle cells. In addition, extensive exposure to environmental'tobacco smoke may result in red'uced! oxygen supply to the myocardium."' "The findings of this study suggest that ar the popula- tion level[ at least among adult men, chronic exposure to environmentall tobacco smoke has little or no effect on leucocyte count." "Despite this finding„ an effect in some heavily exposed individualk cannot be excluded." RESPIRATORY DISEASES AND CONDITIONS - ADULTS. [24] "Effects of Maternal Smoking and Childhood Respiratory Illness on Pulmonary Function in Young Adults: The CARDIA Study," J.E Dunn, S. Kellie, K Liu, and J. Keller, Society for Epidemio- logical Research, 1993 Annual Meeting, Keystone, Colorado, Abstract No. 306, June 1993 "The effects of maternal smoking and childhood respiratory illness (self-report of physician-confirmed asthma, pneumonia or bronchitis before age 10) onn adult pulmonary function were assessed using,the baseline ( Y 985-1986)' data of CARDIA (a study of lifestyle and cardiovascular disease risk factors in~ 5,155 Black (B) and~White (W)„ male (M) and female (F) ~ adults aged 1'$-30 years), Meam FEV1/FVC and FEF25-75 in exposed and unexposed groups were compared withimeach race, sex, and current smoking, status stratum while controlling for age, height, and ETS/1AQ REPORT, ISSUE 52 pack-years of cigarettes. Even when excluding ever- asthmatics, maternalI smoking was associated with lower FEV1i/FVC and FEF25-75 in BF and WF smokers. Childhood pneumonia or, bronchitis was associated with lower FEV 1/FVC in BM and WM non-smokers and WF smokers and! WM non-smokers, all without history of asthma: Excluding those with active asthma, childhood asthma was associated with reduced' FEV 1VFVC in all non-smokers except'WF, as welll as in WM smokers, and with reduced' FEF25-75 in all' non-smokers except WM, as well as in BF and WM smokers. These data suggest that early lung infections and maternal smoking may affecti adulti lling function independ'ently of asthma, and the effect of childhood asthma on aduln l'ung function can be seen in, persons without active asthma." [25] "Passive Smoking and Evolution of Lung Function in Young Adults. An Eight-Year Longitudinal Study," M.S. Jaakkola, J.J.K. Jaakkola, P. Ernst, and M.R. Becklake, American Review ofRespiratory Disease 147(4' Part 2): A215, 1993 "Little is knowmabout the effects of passive smoking on lung function during young adulthood. Our objective was to examine the relation between exposure to environmental tobacco smoke (ETS) and the rate of change of ventilatory lung,function in young adults during a study period of 8 years, with an additional aim to recognize susceptible subgroups.... There was no statistieally significant relation between exposure to ETS during or before the study period and evolution of FEV,or FEFZ5-7g. 25-75.physiologically relevant effect on evolution of ventilatory function is unlikely to be associated with the exposure levelk experienced by our study population. A statistically significant but physi, ologically unimportant relation between cumulative home exposure to ETS before the study and [change in FEVJwas observed in a subgroup of subjects 25 years of age or younger. There was no evidence of modifica- tion by atopy, wheezing or gender. Our results suggest that exposure to ETS in young adulthood in office work environment and at home does not lead to clinically important ventilatory impairment in the exposure levels as experienced in Canadian housing conditions in the 1980's. This does not refute the possibility that higher exposure levels may be harmful_"

JULY 23, 1993 [26] "Effets Sanitaires d'une Exposition Chronique a la Fumee de Tabac sur une Population de Non Fumeurs (Health Effects of Chronic Exposure to Tobacco Smoke on a Non-Smoker Population)" [English abstract only],,A.M. Laurent, A. Bevan, N. Chakroun, Y. Courtois, B. Valois, M. Roussel, B. Festy, and S. Pretet, Rev. PneumoL Clin. 48: 65-70,,1993 "A study devised'! to evaluate the effects of chronic exposure to tobacco smoke on the health of a popula- tion of non~smokers was conducted in a prison." "Fourteen volunteers among male, non-smoking prisonners [sic]', in good health and without history of lung,disease were put for thirty days in a cell that was already occupied by three smokers. These subjects were examined on arrival and on the 30th day of their imprisonment. The examination included filling a questionnaire concerning daily habits and food, respiratory function tests, measurement of CO in the expired air, measurement of nicotine, cotinine, thio- cyanates and.cadmium concentrations in blood and in urine, andmeasurement of mutagenic substances excreted. The purpose of the study was to detect possible changes in the variables tested between the first and last days of confinement." "No significant difference could be demonstrated within this lapse of time. These results are in agree- ment with the data available in the literature. In the present state of our knowledge, it is diffcult to find evidence of a biological impact, notably on the concen- trations of the specific indicators nicotine and'cotinine, in~subjects passively exposed to tobacco smoke." RESPIRATORY DISEASES AND: CONDITIONS - CHILDREN [27] "Privilege and Health - What Is the Connec- tion?" M. Artgell, New England journal of Medicine 329(2): 126-127, 1993 "Anyone who follows the medical literature knows that 'socioeconomic status' is a powerful determinant of health. Irt~ current jargons socioeconomic status refers to a mix of factors that shape a person's relative social advantage. It is usually gauged by income, education, profession, or some combination of the three, but no one knows exactly which factors deter- A-3 mine health, much less how they do so. It does not seem to be simply a matter of the privileged' having better access to health care. Nevertheless, in study after study socioeconomic status emerges as one of the most importano influences on~mortal'iry and morbidity." "So closely does socioeconomic status correlate with that health that it confounds the interpretation of much clinical research. For example, studies of the effect of passive smoking on childhood asthma are uninterpretable unless an attempt is made to control for socioeconomic status. Without such control, it is impossible to know whether the increased prevalence of asthma in the children of smokers is really because of passive smoking or because smokers are more likely to~be poor and'poverry, itself is associated with a hig}ier prevalence of asthma.... Indeed, if the direct effect of a variable under study - for example, passive smoking or exposure to lead - is small, and the effect of socioeconomic status is large, it, may be very difficult to correct for socioeconomic status adequately. In, such instances, stratifying subjects in only a few groups according to income or education may not be svffi- cient. To eliminate entirely the confounding effect of socioeconomic status may require stratifying subjects into a great many subgroups." "Yet, despite the imponance of socioeconomic status to health, no one knows quite how it operates. It is perhaps the most mysterious of the determinants of health. Income, education, and profession are not likely to influence health directly. Instead, these factors are almost certainly proxies for other variables that have a direct impact on health. But what are these variables? Most relevant studies attempt to control for such obvious ones as cigarette smoking and heavy aleohol! consumption, both of which. are more frequent among the disadvan- taged. And the increased frequency of trauma and substance abuse among the poor cannot explain the increased morbidity and mortality from other causes. One O can imagine a host of other influences - such as diet, ~ stress, exposure to infectious agents or toxic chemicals -,~ that are related to socioeconomic status, but there is very 11 little evidence to point to any of them as a major cause of ~ the health difference between.the advantaged and the ~ disadvantaged. "' ~ . "Except for a few special', conditions that afl"ect black ~' Americans disproportionately, such as hypertension, the poorer health of black Americans probably reflects

A-4 other correlates of lower socioeconomic status rather than race itself." "[W]e are too quick to'medicalize' many social ills. For example, we 'treat"drug abuse, as well as kleptoma- nia; compulsive gambling, and a host of other 'co- dependencies.' ...[I]t may be time to reverse this tendency to medicalize, and to be more ready to regard medical illness as the result - direct or indirect - of social' factors. Certainly, there can be little doubt that research on the connection between health and socio- economic status - given the strength of this connec- tion - would yield important information about the pathophysiology of disease." "Dealing with the social causes of disease and re- sponding to its medical effects are not mutually exclusive. We should do:both, People already burdenedl by poverty and lack of education should not also carry a disproportionate share of illness." [28] "Is Passive Smoking a Cause of Asthma in Childhood?"'R. Ehrlich, M. Kattan, and D.E. Lilienfeld, Journal of Smoking-Related Disorders 4(2): 91-99, 1993 "The number of epidemiological studies of the association between passive smoking,and asthma and wheezing in children~ is growing and the aim of this review is to re-examine the epidemiological evidence. Because of underdiagnosis of asthma and the difficul- ties of defining asthma for epidemiological purposes, wheezing as well as non-specific bronchial hyperresponsiveness are included'as outcomes of interest, although they inay lack some specificity for clinical asthma. For purposes of exposition, the epidemiological I studies are divided according to the type of population studied, viz- general population studies and studies of asthmatics using health services. These in turn are further grouped according to study designi" "Despite inconsistency among the studies reviewed; a coherent pattern is emerging, Imparticular, studies which have been able to separate out maternal'smoking have been more consistently positive than those that did not make this distinction. Further, among the studies which quantified' maternal smoking, nearly all have been able to show some exposure-response relationship between maternal smoking and some measure of asthma or wheeze." ETS/IAQ REPORT, ISSUE 52 "In~ generaL the evidence for an effect of passive smoking on wheezingandlother lbwer respiratory illness is more consistent for children under two years of age than that for older children," "Despite the emerging evidence concerning the impor- tance of maternal smoking, variation~remains among study findings, and this is likely to continue. Part of this variation between studies is due to the difliculties of measuring accurately the child's true dose of smoke exposure. Furthermore, ETS is a complex mixture of agents, any or a number of which may be implicated." "The association between maternal smoking and asthma and wheezing illness in children satisfies a number of the criteria for causality. There is reasonable consistency among studies, an exposure-response relationship has been demonstrated and an appropriate temporal relationship established in prospective studies." "Pn addition, the association has biological'plausibiliry although the mechanism remains to be defined„and there is not strong evidence that confounding accounts for the observed increase in risk."' "From a public health perspective the impact of such a causal relationship is considerable. Assuming a relative risk of asthma due to: maternal smoking of 1.5,. after controlling for confounding, and a maternal smoking prevalence of 30%, an attributable proportion of 113% can be calculated. This is the proportion of asthma and persistent wheeze in childhood that could be prevented! in the absence of maternal smoking. This should add further weight to public health, clinical and educational efforts to reduce the burden of illhealth, [sic]I imposed on young children by the tobacco smoking habiC" ETS Exl>OSURE A1vD MONITORING [29] "Measuring Exposure to Environmental To- bacco Smoke in Studies of Acute Health Ef- fects," M.C. Marbury, S.If. Hammond, and N.J. Haley, American Journal of Epidemiology 137(10): 1089-1097, 1993 "In preparation for an investigation of environmental tobacco smoke and lower respiratory illness in~children under 2 years of age, we conducted a study to compare methods of characterizing exposure to environmeotal tobacco smoke, induding questionnaires, urinary

JULY 23, 1993 cotinine measurement, and ambient nicotine measure- ment. Our purposes were to examine the relations among the three measures and their variability over time and to assess feasibility and logistic issues. Al- though ventilation~ rates were not measured, the study was conducted during a period when rates were expected to:be stable." "Thirteen girls and 35 boys under 2'years of age, all non-Hispanic white, were enrolled in the study. In 23 homes neither parent smoked; five homes were in the low exposure group." "All three measured varied significantly, depending on which parent(is) smoked. Concentrations of ambi- ent nicotine and urinary cotinine were higher when the mother smoked than when the father smoked and highest when both parents smoked." "In this study, we initially compared three differentt methods of estimating exposure, questionnaire, urinary cotinine, and ambient nicotine, on a cross-sectional basis in a population with varying degrees of exposure. Urinary cotinine and ambient nicotine concentrations were highly correlated with each other. This correlation~ suggests that, even though one is a measure of exposure and the other a measure of dose, they provide equally valid but redundant, information about exposure in this study population." "Given equal validity, the choice between the two measures then depends on feasibility. Ohe component of feasibility is the variability of the measure, as greater, variability requires that more measurements be made for accurate exposure estimation. While both measure- ments showed variability over time, urine cotinine was more variable."' "[WJe found'that one measurement of ambient nicotine during an 8-week period; when ventilation rates are relatively stable, would be adequate for achieving reasonable precision in our exposure esti: mate. In contrast, three measures of urinary cotinine would be needed to obtain the same degree of preci- sion. In addition, we were able to collect complete dataa on ambient nicotine measurements, whereas we were unable to obtain urine samples at 20 percent of the visits. Thus, for this study population, air monitoring of nicotine is more feasible." "[QJ luestionnai'res will undoubtedly continue to be used in studies of environmental tobacco~smoke, either A-5 as the whole or as a part of the assessment strategy. V{/hen used in conjunction with an objective marker,, each can be used to help interpret the other. For example, in the cross-sectionall study, both~ the pattern of activity room nicotine concentrations and urinary cotinine levels indicated'that fathers smoked fewer cigarettes in the house than mothers, although fathers were reported to have smoked more. This was not due to a difference in where the fathers smoked„as all fathers were reported to have smoked in the living room or family room." "[T]he pilot study provided information on the use of nicotine sampl'ers. Placing nicotine samplers in both the activity room and''the bedroom~ is unnecessary. The concentrations in the two rooms were highly correlated' throughout the study." INDOOR AIR QUALITY' [30) "Indoor Air: Potential Health Risks Related to Residential Wood Smoke, as Determined Under the Assumptions of the US EPA Risk Assess- ment Model," K.S: Sidhu, J.L. Hesse, and A.W. Bloomer, Indoor Enuironment 2: 92-97, 1993 "Residentiallwood smoke contains inorganic and organic particulates, ash, carbon monoxide, nitric oxide, nitrogen dioxide, formaldehyde, polycyclic aromatic hydrocarbons (benzo[a]pyrene„ benzo[k]fluoranthene, benzo[b]fluoranthene„ benzo['ghilperylene, and'~indeno[1,2,3-cd]pyrene), phenols and sulfur dioxide. Benzo[la]pyrene and formaldehyde are classified as group B'z,and group B, carcinogens, respectively, by the United States Envi- ronmentall Protection Agency. Reported concentrations and potential health risks of the released contaminants are discussed~ In general, wood smoke is an irritant to the eyes,, nose,, and the respiratory tract. It has the potentialito cause chronic respiratory problems, Because there are indications that wood smoke may cause adverse effects on human healths exposure to this source of air pollution should be minimized." "The objectives of this paper are to formulate cancer risk assessments and to review the potential healthh effects of several indoor air contaminants released by wood-burning stoves." "The exposure assessment and risk characterization for formaldehyde released from non-airtight wood'•