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A Rebuttal t0 t11e Tobacco Industry's Paper, "Cigarette Smoke andi the Nonsmoker"' VIRGINIA ERNSTER and DAVID BURNS The constituents of tobacco snnoke arc uvell-doeriurntcd as &azardous, the preva- lence of popu lution exposnre is vcry high and there is ari increased incidrnce of respiratory tract, syniptomu airditrnctional drerePnents (decreases) ik cl,ild'ren residg inQ in liornes ivith sinolecrs. Thcsc+ considerations and recent evidcncc of irurcased' hrngt cancer ratcs an:ong noyi-sn:okirig tvoutc7t l'iving tvit'li sinoking husbands have led'us to conclude that indoor e.cposnrc to to6nuo, sinoke has adi,rrse &ects. Public policy should clearly articulate tliat' involiintary exposure to tolracco~sritoke ought to be minitnizrd'or avoidrd ueliere possible. National Rcscarcli Council (i) rGtior+o-z~ ATERIALS prepared by tobacco industry representa- eJ tiwes are diesigned to discredit any links between expo- ~ sure to secondhand smoke and disease. These materials need to bc understood in context, for the tobacco in: _ "-- dustry eontinues to assert that thcre is no evidence cstablishing any adversc health eff+eat of smoking even for individuals who smoke heavily. No scientific group reviewing the medical evidence inAe last i S years has expressedy any doubt that cigarette smoking, causes disease. Only the tobacco industry attempts to make thee issue appear controversial. This has been a long-standing; strategy that was reveale&in an industry document ciitedlin the pederal''Trade Cornniission's report of May 1981 on cigarette advertising. Internal documents from a nzajor U.S: tobacco company describe their public information eiforts as follows: Doubt is our product since it is the best means of:'competing with the 'body of fact' that exists in the mind of'the gcneral public. It is also the mcans of atablisltiing a controversy (2). 368 I S-14

ERD71S'TER & BURNS • A REBUTTAL 369 Thcrcforc it is not surprising that thc industry has adbptcd a similar strat- cgy with respcct to involuntary smoking, nanicly, citing cvidcnce selec- tivrly and quoting scic*ntists out of contc.xt. P'rovidrd hcrr arc cxamaplcs of the tobacco indiastry's rcccnt misreprc- scntation of statcmcnts fro~nt the scientific literature in its position paper cntitlcul! "Cigarcttc Snvokc and the NionstnokR:.r." That paper or similar vcrsions havc bccm passed out by industry public rclations representatives to lcgislators in California. The papcr includes many of'the points that Tobacco Institutc represeirtatiwes make rcgarding t'1ac !c&cts of involuntary smoking', in the course of public hcarings and radio and television appear- ainccs. It sccnned, appropriate to have thrsc points discussed ina published papcr that could bc uscd by those who work to promote nonsmoking policies through, legislativc or, other rneans. The indlustry papcr takes to task the results' of a study comducted at, the University of California, San Diego, and published in the New &rigland' . Jnirrn al of Medicinc (3 ) whiich showed'' that nonsmokers exposed to tobacco smoke at work had reduced function, of small airways compared to non- exposed nonsmokers: White and Froeb, the authors of that study, reported that "iflbng-termismall-airways dysfunctionis occurring, the non-smokers who work in a smoky environment have about the same risk of impair- ment as do smokers who do not inhale and smokers who inhale between one and io cigarettes per day." " In an attempt to downplay these findangs, the industry paper quotes from an editorial' written by Dr. Claude Lenfant of the National Heart, Lung,and'Blood' Institute: "The eviidence that pas- sive smoking, in a general atmosphere has health effects reaaains sparse, incoasplete, and' sometinaes unconvmcing." However, reading the entire editorial from which this quote was taken gives the reader a different impression. Dr. Lenfant went on to say: The article!by WJhite and Fro&... brings a new dimension that will' clearly, have considerable impact; they faultlessly demonstrate a re- duction in measures of snzall'~ airways of healthy nonsmokers expose& to cigarette smoke in the workplace ... now, for the first time, we have a quantitative mcasurement of physical change--a fact that may tip the ! scales in favor of the nonsmokr.rs (4). In i98o, whem a statewide initiative to restrict smoking in public places was on the California ballot (Proposition io), thc industry-sponsored carna- pa2gmi to dcfcat the initiative agairn uscd Dr. Lenfant's words selectively. s-is

370 JOURNAL OF P'U,BLIC' IiIEALT'II POLICY • SEPTEMBER 1984 In a telcgram (dated~ October 24, 198b) to the supporters of thc initiative, Dr. I:enfaait said, The tobacco companies arc quoting me out of context and niisrcprc-• senting my personal views on the harmful!effectofsecondhand smoke. I personally endorsc ~ Proposition io ~ includang, the five medical find- ings that'secondhand smoking canharm the nonsmokcr especially the millions of people with hcart.andl lung diseases. The industry paper attempts' to downplay cigarette smoke as a signifi- cant source of carbon monoxide in~ the environment. It claims that at+ nnospheric carbom monoxide fronn tobacco smoke rarely exceeds io partss per milli=aaid' is closcr to S parts per million in public places' with normal ventilation, and, that "both f gures are well below the limit of so parts per million recommendedl by health agencies for workers exposed over an eight-hour period: ° It is important to note that the so parts per million is an occupational standard over an eight: liour pcriod, not the recommended air' quality,standard, whichisnine~ parts per million. Thei979S'urgeon Generalrs' report notes that, "Occasionally, under conditions of heavy smoking and poor ventilation, the maxinauln limit for an 8~hour work exposure to carbon monoxide ($o~ parts: per million) may be exceeded. The upper limit for carbon monoxide in ambient air (9 parts per million) may be exceeded even in cascs where ventilation is adequate" (6)'. The industry paper later suggests that carbon monoxide is not a cause of heart disease, citing the fact that members of certain occupations ex- posed, to high Ievels of carboni monoxide on, a regular basis do not have ex-cess rates of cardaovascular disease. However, they fail to note that smokcrs in those occupations have higher rates of cardiovascular disease than their countcrparts' who do not smoke. Thus, whether the carbon monoxid'c conzponcnt of cigarettes is the culprit is a raoorpoint. Cigarette smoke is the issue and, there is no doubt that cigarette smoke can cause cardiovascular disease; thc 1983 report of the Surgeon General concluded that smoking should be considered tlie most important of the known nnodifiabl'c risk factors for coronary hcart disease (7). The industry paper also attempts to; downplay cigarcttc smoke as an important source of particulate matter, noting, that "airbo'nne particulatc rttattcr arises froini many sources besides tobacco smoke." However, ac- cording to the 1981 rcpprt on indoor pollution issued by the National Academy of Sciences, "For inany people, the maiuni or sole exposure to nunicrous gascpus and particulate compound's results from passive expo-

. ruNSTER & BltltNiS • A REBUTTAL 371' sure to tobacco snnokc"' and "Snnoking, is the major sourcc of indoor particles . . ." (i). Tlu authors of a paper published in the Auucricart Jorrrrral of Public Hcaltll found that ""Conccntrations of the irritants formaldehyde anud acrol6'n in side stream cigarcttc smol:c lplunncs are up to three orders of unagniteidc above occuraticonal' limits, readily accounting for eye and nasal irritation" (8);. A paper in Scivnn"rcp(Irtl:d that IndlDor tobacco conn- bu5tion cnaits Ilirotinc, poly,cyclic aromatic hy,drocarbons, carbon monax-- idic, acrolcin, N Os, and many other substances (9);, its authors cite earlier work (to) showing that wlicrc two or more heavy smokers resided in a house with low air exchange rates, the 24 hour I*lationall Ambient Air Quality Standard for indoor particle concentrations was violated. Inclnd'cd is a, table from the i979 Surgcion! General's report which lists constituents of cigarette smoke atldi shows their ratio in sidrstrcalm, compared to Imrain- strcanl smoke. This list includes a number of known carcinogcns.. (Scnsitivc scientific measurements arc not rcquircd'to detect the presence of cigarette smoke in the air. It is readily apparent to the human eye and' IlOSc.)' The issue of wlnich component of cigarette smoke is the best ialdiutor of exposure has ~ not been resolved by scientists. The industry has widely quoted a 1975 study that showed that "a nonsmoker would have to spend ioo hours straight in the smokiest bar to "absorb"' the [nicotine) equivalentt of a, single filtcrtip cigarette''' (iii~). However, nicotine tends to settle out of the air fairly quickly and' is not a good indicator of total exposure (iz). Tloc industry paper states that the Surgeon General's report of 1982. '`n4tcd that, the available evidence is not sufficient to conclude that other peoplc's: smoke causes dlsease in nonsmokers." They chose not to cite the Surgeon General's full condusion, i.e.: "Although the currently available evidence is not sufficient to conclude that passive or involuntary smoking causes hung caiiccr ini nonsmokers, the evidence docs! raise concern about a possible serious public health problem!" (S). They also ignored the fore- word to the report by Assistant Secretary for Health, Edward Brandk, M.D., who stated'; While the nature of this association is unresolvcd', it docs raise the con- cern that involuntary smoking may pose a carcinogenic risk to the nonstnokcr. Anyhcaircli risk resulting from involuntary smoke cxpos- sure is a serious public health concern because of thrlarge numbers of nonsmokers in thc population who arc potentially cxposcd. Thcre- fore, for the purposes of preventive nicdicinc, prudcilcc diictatcs tlrat

Constituents of Cigarette Smoke.t Ratio of Sidestream Smoke (SS) to Mainstream Smoke (MS) Gas Phase MS SS/MS MS SS/MS Carbon Dioxide Carbo>; Monoxide 20-60 mg 10-20 mg 8.; 2.5 Nitrogen Oxides (NO=) Ammonia - 80 Ag - 73 Methane 1.3 mg 3.1 Hydrogen cyanide 430 µg 0.25 Acetylene 27 µg 0.8 Acetonitrile 120 µg 3•9 Propane Propene o.; mg 4.1 Pyridine 32 µg 10 Methylchloride o.65 mg 2.1 3-Picoline 24 µg 13 Methylfuran 20 Ng 3.4 3-Vinylpyridine 23 pg 28 Propionaldchyde 40 pg 2.4 DimEthylniEtosamine io-6; µg 52 2-Butanone Acetone 80-250 µg ioo-60o µg 2.9 Nitrospyrrolidinc 1o--3S µg 27 Particulate ' Phase MS SS/MS MS SS/MS "Tar" 1-40 mg 1.7 Benzo(a)pyrene 20-40 µg 3-4 3Vater i 4 sng 2.4 Quinoline 1.7 Pg is Toluene 109 µg 3.6 Methylquinolines 0.7 µg si Stigmasterol ;3 µg 0.8 Aniline 36o ng 30 Total Phytosterols 130 Pg 0.8 zrNaphthylamine 2 ng 39 Phenol 2o-i 3o µg 2.6 4 AminobiphEt_tyl 5 ng 31 C-2techol 130-280 µg 0.7 Hydrazine 32 ng 3 Naphthalene 2.8 µg i6 N'-Nitrosonornicotine roo-5oo ng 5 Methylnaphthalene 2.2 ;Ag 28 NNK2 8o-zzo ng io Pyrene 50-200 µg 3.6 Nicotine 1: 2.5 mg 2.7 i Nonftlter cigarette ? NNK = 4-(N-methyl-N-nitrosamino)-s-(3-pyridyl)-t-butanone (tobacco specific carcinogenic nitrosamine) souace: U.S. Depattment of Health, Education, and Welfare: Smoking anAHealch: A Report ofjdu Surgeon Cnenal_ DHEW Publication No. (PHS) 79--Soo6tS. Washington. D.C.: U.S. Government Printing Office, 1979. s4vts9szo%

ERNSTER & BURNS • A REBUTTAL 373 nonsmokers avoidi eaposure to second-hand tobacco smoke to the cxtcnt possiblc. With respcct to studies of involuntary smoking and lung cancer, the industry paper nlcnmiio'nstwostudies (13,14), that have showm, aposiitiive cf$'rct. However, after citing criticisms of those studies and noting that an American Cancer Society study (is) produced "`contradictory results," the industry paper concludes that claims of increased ri51: are "highly sus. pcct"' andl "not provcn." It should be noted that the American Cancer Society study did show an excess of'lung cancer deaths among nonsniok: ing, women marricd! to smokers but that this finding was not statistically significant. INiorcover„ the study wasn't originally, ddesigned to examine the cffccts of involuntary smoking and so the investigators only hadi in- formation about the e:cposurc to cigarette smoking by spouses; among American women, spouse's smoking is probably not an adequate measure of total exposure to secondhand smoke. The tobacco indiusuy has publicly distorted! the scientific dlsicussion of lung ancer, in full-page ads in popular American magalincs and newspapers ini an attempt m dioud' the entire area of health, effects of 'involuntary smoking. A more recent study from New Orleans found that lung cancer risk was increasred among nonsmokers married to smokers (0)r The industry paper very selectively cites'lfterature relevant to the health effects in children of involuntary exposure to their pazents' cigarette smoke. Two negative studies are cited, thereby ignoring the nusnerous reports of increased risks of respiratory disease and allergics and more sick days among, children whose parents smoke compared to the children of non- smokers (12-,17). A reoently published study in the New Englandjoumal of Medicine showed reduced lung fitnction in children whose mothers smoke cigarettes (18): Other workers~ have shown that cotinine, a brcakdbwn product of nicotine, is detectable in the amniotic fluid of nonsmoking pregnant women who are exposed to the cigarette smoke of others (19). Commenting on public concern about involuntary exposure to ciga- rettie smoke, the industry document quotes from the Surgeon General's report of 1979that'responses~ observed"may be due topsycholiog}aal' fac- tors." The latter statement referred only to die changes in heart rate and blood pressure found in children and was not suggested in relation to other ccalthi cf~'~ccts, nor was it one of the overall conclusions of the report. Moreover, it was written before some important studies linking involun- tary smoking witln, disease were published. C S-19

jo.* Jvwu.iV1%L ur PuIsLJL J!L•ICL'TJ1 Y'UL1iCY • SEPTEMBER 1984 FFinally, the industry paper al'togctlicr omits discussion of frcquent rc- ports of eye, nasal and throat irritation itt nonsznokcrs cxposcd to cigarette smoke and the fact that certaut allergic symptoms appear to be triggcredd by exposure to cigarctxe stnokc (1 7);. Moreover, tlie Accm"beyondhcalth" deserve attention: people have a right to breathe clcan air.. SUMMARY There is no reasonable doubt that cigarette smoking causes cancer, heart disease, lung disease, and complications of pregnancy. Smoking is respon- sible for an estimated 340,000 deaths among Americans each year (6), making it die number one known preverntable cau5e of disease in this country. The question at hand is not whether smoke can cause heart and lung disease and cancer but. rather whether the dose of this agent received by the secondhand or involuntary smoker is large enough to cause disease. A growing body of work suggests that the consequences of this level of exposure may go far beyond the simple eye and throat irritation com- monly experienccd. Im the face of this evidence, the burden of proof shifts to those who~ would expose the nonsmoker to an agent that in higher doses is clrarly deadly. For until it is proven safe, as the Assistant Secretary for Health has said, based on our current leveli of understanding, ". .. prudence dictates tharnonsnnokers avoid exposure to second~-hand tobacco smoke to the extent possible: " REFERENiCESS i. Committee on Indoor Pollutants, Nationali Research Council. Indoor IDbllrrt'- talus. Washington, D.C.: National Acadctny Press, 1981. 2. Mycrs, M: L., C. Iscac, C. Jtnnings, W. Lcnox, E: Minsky, and A. Sacks. Federal Trade Connirission Stn'Riport'oii the Cigarette Advertising Investigation, May' 198r. 3. Whitr„ J. R., and' H. F. Frocb. "Sinall-ainvays dysfianction in nonsmokers chronically cxposcd to tobacco sniokc,'"' Nrcu England Jorrnnal' of Medicine 3022 (1980): 73o-a3. 4. Lcnfant, C:,andl3. M.Liii."(Passivc)' Sinokcrs Versus (Woluntzry) Snlokers,"' Nrit, Eqlnnd Jwr+rual'of ll fadiriatr 302 (198b) : 74a-43!. S. U.S. Public Health Service. Tlic Healtli Cnnsrqr+cuces of SmoLtibg: Cancer. A Rcport, of tJre S,qroij! Ccnrrrrl: Jg82: U.S. Department of Hcalthand'H~unnan

f F.'RIiiIS'T'T:R' & BURNS • A REBUTTAL 375 Scrviccs, Public Health Service, Officc on Smoking and Health, DHHS Publication No. (PHS) 82-Soi79, 1982. C6. U.S. Public Health Service. Stauoking artJ Hralt&. A Rcport' of the Surgeon Gcnrral: tg79. U.S: Drpartnicnt of Hcalth, Education, atnd', Welfare, Public Hcalth Service, Odiicc on Smoking and Hcalth, DHEW Publication No, (I'HS)' 79-5oo66+ 1979- 7,: U.S. Pitblic Ht~1th Service. Tlre Health Consequences of Smoking: Cardiovas- calnr Disease. A Report of the Sinqcon General: Ptockvillic, Maryland: Public Hlralth Scrvicc, Officc on Smoking and Hea'lth, DHHS, 1983. 8. Ayer, H. E:, and D: W. Yeager. "'Irritants in CiSarerre Smoke Plumm,," Anirrican Joimtal, of Anblit Hralth 7Z (198Z): rz83-85. 9. Spcnglicr, J. D., and' IL Sexton. "'IUdbor Air Polliution: A Public Health Pt:rspcctivc,," Sairrue ZZi' (i983):' g-t7• 1 o. Spcnglicr, J. D:, ct al. "Long-tc= Measurements of Respirable Sulfates and Partiidcs Inside and Outside Homes," Atmosphere and Environnurtt'i S (i98i): a3-8©. s i. Hinds, W., and M., F'irst. "Concentratibns of Nicotine and Tobacco Smoke in Public Places; ' New Eigl+mul Jburnal of Medicine 202 (i975) : 844-54• 12. U.S. Public Health ' Service. Chapter 7: "Passive Ssnoking," in The Health Consequences of Smoking: Chronic Obstructive Lung Disease. A Report of tlu. Surgeon General. U.S.; Department of Health and'Hutnam Services, Public Hicalth~ Scrvice, Officc on Smoking an& Health, DHHS Publication No. (PHS) 84-50205, i984.. i3. Hirayama, T. "Non-smokimg, Wives of Heavy Smokers Have a~ Hagher Risk of Lung Cancer: A Study from Japan," British Afedical Journal ! z8x (1984: 183-85. 14. Trichopoulos,,D., A. Kalandidi, L. Sparros, B. MacMahon. "Lung, Cancer and Passive Smoking," Interaatuonal jormsal of Cancer 27 (i981). s¢. is: Garfinkel, L "Time Trends in Lung Cancer Mbrmlity Arnong Nonsmokers and a Note on Passivc Smoking," Journal'of the National Cancer Institute 66 (iq87): io6i-66. 16. Corrca, P:, , L W. Pickle, E: Fontham, Y. Lin; W. Hacnszel. "Passive Smoking and Lung Cancer,,' La"cct' ii (s983):':595-97. 17. Shephard, R. J,. The Risks of Passive Smoking. New York: Oxford University Press, v98Z. 18. . Tager, I. B., S. T: Weiss, A. Munoz, ct al. "Longitudinal Study of the Ed"ectsof lwlatcrnal Smoking on Pulmonary Function in Children;' New England Jo:rrolal of Medkine 309 (19'83): 699-7031. s9. Smith, N.,,J. Austen, C. JG Rolles. "Tcrtiary Smoking by the Fetus," Lmuet i' (i98z): 12,52. c S-2i