HomeMy WebLinkAbout31- Council Office CITY OF SAN BER[ RDINO - REQUEST OR COUNCIL ACTION
From: Councilman F.J . Curlin, M.D. Subject: Smoking Ordinance Amendment
Second Ward
Dept: Council Office
Date: June 29 , 1993
Synopsis of Previous Council action:
Recommended motion:
See attached
r ow
dF Signa ure
Contact person: Phil Arvi zo Phone: 5208
Supporting data attached: Ward:
FUNDING REQUIREMENTS: Amount:
Source: (Acct. No.)
(Acct. Description)
Finance:
Council Notes:
75-0262 Aaenda Item Nn_-CR/
E
CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
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To set a Public Hearing to :
1 . Amend Chapter 8 . 72, Section 050 "Smoking in restaurants" ,
subdivision "A" to read "Smoking is prohibited and unlawful within
all enclosed restaurants" .
2 . Amend Subdivision "B" to read as follows : Restaurants
with a seating capacity of more than 50 persons located in a dance
club, excluding from that calculation of capacity any portion of
such facility which is located outdoors and/or which is utilized as
a bar, shall have a portion of the dining area designated as a non-
smoking area. The non-smoking area required by this paragraph must
be a contiguously maintained indoor area comprised of at least 50%
of both the seating capacity and floor space of the area in which
customers are being served.
3 . Add Section "C" - the prohibition set forth in paragraphs
a and b above, shall not apply to any portion of a restaurant which
is utilized as a bar, or to any rooms which are being used for
private functions, but only while any such rooms are used for such
private functions .
CITY OF SAN BERNARDINO - REQUEST FOR COUNCIL ACTION
STAFF REPORT
Over 25 years ago, research at the Sloan-Kettering Institute
in New York City (Dr. Wynder Study) , demonstrated, by the use of
smoking robots, the direct relationship between tobacco use and
cancer. Since that time, a host of other disease conditions,
including heart disease, emphysema, low birth weight in newborns,
etc . , have been also related to tobacco abuse .
The most dramatic revelations, however, have been the recent
indictment of smoking abuse insofar as it affects non-smokers by
their inhalation of exhaled and sidestream smoke .
It is estimated that each year 430, 000 Americans die as a
direct result of smoking. In addition, more importantly, it is
estimated that 53 , 000 non smoking Americans die each year as a
result of their exposure to sidestream and exhaled smoke in their
homes and in the work place .
Economic loss incurred by United States businesses, as a
direct result of smoking, is a staggering 52 billion dollars a
year. This ordinance modification is geared to protect the rights
and health of the general public and is in harmony with parallel
legislation, past and pending, in 541 localities and 46 States,
including the City of Los Angeles (passed by the Los Angeles City
Council June 23 , 1993) .
a
S
1 ORDINANCE NO.
2 AN ORDINANCE OF THE CITY OF SAN BERNARDINO AMENDING CHAPTER
8.72 OF THE SAN BERNARDINO MUNICIPAL CODE RELATING TO SMOKING IN
3 RESTAURANTS.
4 THE MAYOR AND COMMON COUNCIL OF THE CITY OF SAN BERNARDINO
DO ORDAIN AS FOLLOWS:
5
6 SECTION 1. Section 8.72.050 of the San Bernardino
7 Municipal Code is hereby amended to read as follows:
8 "8.72.050. Smoking in Restaurants.
9 "A. Smoking is prohibited and unlawful within
10 all enclosed restaurants.
11 "B. The prohibition set forth in Section A shall
12 not apply to restaurants with a seating capacity of
13 more than 50 persons located in a dance club,
14 excluding from that calculation of capacity any
15 portion of such facility which is located outdoors
16 and/or which is utilized as a bar, as long as such
17 restaurant shall have a portion of the dining area
is designated as a non-smoking area. The non-smoking
19 area required by this Section must be a contiguously
20 maintained indoor area comprised of at least 50
21 percent of both the seating capacity and floor space
22 of the area in which customers are being served.
23 it C. The prohibition set forth in this Section
24 shall not apply to any portion of a restaurant which
25 is utilized as a bar, or to any rooms which are being
26 used for private functions, but only while any such
27
2s
DAB/bg (Smoking.Ord] 1 June 30. 1993
�� �_
1 rooms are used for such private functions, or to any
2 portions of the restaurant which are located outdoors
3 or are open to the sky. "
4 SECTION 2. Subsection C of Section 8.72.090 is hereby
5 amended to read as follows:
6 "C. Any person who violates Subsection A of this
7 Section or any person or business who violates
8 Subsection B of this Section, except as otherwise
9 provided herein, shall be guilty of an infraction,
10 punishable as set forth in San Bernardino Municipal
11 Code 91 . 12(B ) . "
12
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10
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20
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DAB/bg [Smoking.Ord] 2 June 30, 1993
Alow
1 AN ORDINANCE OF THE CITY OF SAN BERNARDINO AMENDING CHAPTER
8.72 OF THE SAN BERNARDINO MUNICIPAL CODE RELATING TO SMOKING IN
2 RESTAURANTS.
3 I HEREBY CERTIFY that the foregoing Ordinance was duly
4 adopted by the Mayor and Common Council of the City of San
5 Bernardino at a meeting thereof, held on the
6 day of 1993, by the following vote, to wit:
7 Council Members: AYES NAYS ABSTAIN ABSENT
8 NEGRETE
9 CURLIN
10 HERNANDEZ
11 OBERHELMAN
12 OFFICE VACANT
13 POPE-LUDLAM
14 MILLER
15
16
17 City Clerk
18 The foregoing Ordinance is hereby approved this day
19 of 1993.
20 Tom Minor, Mayor
City of San Bernardino
21
22 Approved as to form
and legal content:
23 JAMES F. PENMAN,
24 City Attorney
25
26 By:
27
28
DAB/bg (Smoking-Ord] 3 June 30, 1993
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C O A L I T I O N F O R A
Tobacco-Free San Bernardino County
505 North Arrowhead Avenue, Suite 500, San Bernardino, CA 92415-0048
1-800-637-6653 Telephone (909) 387-6000 Fax (909) 387-6006
July 19, 1993
MEMBER AGENCIES
Mayor Tom Minor
American Cancer Society City of San Bernardino
300 N. D Street
American Heart Association San Bernardino, CA 92401
American Lung Association
Dear Mayor Minor:
Behavioral Health Institute at Cal
State University San Bernardino
As Chair of the Coalition for a Tobacco-Free San
California Nurses Association Bernardino County I am writing to commend the city of
San Bernardino for considering an ordinance concerning
Chino Hills Advocates for a smoking in restaurants. Such efforts can help protect
Smokefree Environment(CHASE) adults, children and restaurant employees from the
harmful effects of secondhand smoke. Such legislation
Crafton Hills College will help reduce the 53, 000 deaths each year caused by
secondhand smoke exposure. Our coalition and its
Inland County Health individual members stand ready to assist the city in
Systems Agency any way possible to further our goal of a tobacco free
county.
Inland Empire Hispanic News
Kaiser Permanente Sincerely,
Libreria del Pueblo 64kt 1.-('�c Tu I y Pa( n'e
Loma Linda University Laurie Tully-Payne
Center for Health Promotion Chairperson
Coalition for a Tobacco-Free San Bernardino County
San Bernardino County
Medical Center
San Bernardino County
Medical Society
San Bernardino County
Department of Public Health
San Bernardino County
Superintendent of Schools
Tri-County Dental Association
X31
MdMM r
CBRA Nietts
i
i
California Business and Restaurant Alliance
EPA Report Will Have No Impact on Workers' Comp
Last January,the Environmental Protection Agency that two months of on-the-job secondhand smoke
(EPA) released a report on environmental tobacco exposure would have the impact of one cigarette;for a
smoke (ETS),commonly referred to as secondhand restaurant patron, it would take an entire year's worth
smoke. The report states that secondhand tobacco of lunches to have the same impact.
smoke creates an increased risk of lung cancer and is One of the most obvious omissions in the EPA
responsible for 3,000 deaths every year. report is a recent National Cancer Institute study on
Since its well-publicized release,the EPA report secondhand smoke. It is perhaps significant to point
has been hailed by anti-smoking activists as the out that the National Cancer Institute study does not
evidence they need to put an end to smoking in all find any increased risk of lung cancer from secondhand
public places including restaurants,hotels,bars, smoke. In addition,the EPA report ignored its own
bowling centers and race tracks. Their claim is that the standards by increasing the allowable margin of error.
EPA report provides the legal leverage for use in Had traditional methods been used,they would have
workers'compensation cases. shown no increased risk.
Anti-smoking activists are misusing the EPA report EPA Report Impacts on Workers' Compensation
to try to get government to further regulate our Liability
businesses. The EPA report does not change employer liability
EPA Report Flawed regarding workers'compensation or common-law cases
The most cursory review of the EPA report reveals involving secondhand smoke in the workplace.
the glaring fallacy of the anti-smoking activist Secondhand smoke, specifically ETS, has already been
arguments. The EPA risk assessment is based entirely listed under California's Proposition 65 as a known
on studies in the homes of nonsmoking spouses of carcinogen since 1989.
smokers—not in a single restaurant,workplace or Further,the State of California has concluded that
public place. secondhand smoke is one of more than 300 substances
Fails to Study Secondhand Smoke commonly found in the environment that can cause
in Restaurants cancer.
Not included in the EPA report are a number of Just because ETS is listed under Proposition 65,
studies which specifically measure ETS levels in does not improve a claimant's charges of prevailing in
restaurants. In fact,these studies conclude that a workers'compensation litigation over secondhand
person would have to spend several hundred hours in a smoke. Even if a court were to accept the EPA report's
typical restaurant to be exposed to the nicotine conclusion that secondhand smoke is capable of
equivalent of a single cigarette. causing cancer,a claimant would still have to
For a typical waiter or waitress,that would mean (Continued on page 3)
"From a legal standpoint, the EPA
Report has no more judicial ■ EPA Report Will Have No Impact on Workers'
significance than (previous) reports by Comp page 1
the Surgeon General and the Nation ■ Assembly Bill 13 vs Assembly Bill 996 pages 2
Academy of Sciences." &3
John Fox ■ An Expert's Opinion: John Fox's Testimony on
(See story on page 4) AB 13 page 4
■ Did You Know?page 4
Spring 1993 • CBRANews 1
PE" ^ION FOR CLEAN INDOOR AIR 1A e,°�
in the City of San Bernardino
WHEREAS,numerous studies have found that tobacco smoke is a major contributor to indoor air
-)Ilution;and that secondhand smoke kills 53,000 nonsmokers in the United States each year and,
WH�FREAS. reliable studies, including the Environmental Protection Agency's report on passive
smoke, have shown that breathing sidestream or secondhand smoke is a significant health hazard;and
WHEREAS.health hazards induced by breathing sidestream or secondhand smoke include lung cancer,
respiratory infection,decreased exercise tolerance,decreased respiratory function,bronchia-constriction,
ind bronchospasm; and
WHEREAS.the Surgeon General of the United States has advised nonsmokers to avoid exposure to
tobacco smoke wherever possible,and in particular, to protect infants and children from this smoke;
NOW THEREFORE_we as residents,request the city council to enact an ordinance that prohibits
smoking in all enclosed areas including restaurants,workplaces,and recreational facilities. We request that
the city council protect the public health and welfare and guarantee the right of nonsmokers to breathe
smoke-free air,and to recognize the need to breathe smoke-free air shall have priority over the desire to
srpoke. C--�---
I Q
N R
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YOUR NAME d P
c
TUBE RESIDENCE ADDRESS /
(Vail 16 q.2- 6 S
A0
PRINT YOUR NAME QTY ZIP
3
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TURE RESIDENT ADDRESS
PRINT YOUR NAME CITY ZIP
S�NA RESIDENCE ADDRESS
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5 402P Z-C10('L.tom l
TURE RESIDENCE ADDRESS
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73
SMOKING ORDINANCE
IN FAVOR OP: AGAINST:
E-6 there J-i.menez--imea-am
Angie Tocchin.i
6825 R.idgezide Dt. D � 848 W. 20th St.
Riveuide, Ca 5� y Phone: 882-9746
Phone: 387-6000 t�
Ap it Ganc i.a.
132 W. Joh"ton
Sharon Leyden Cotton, Ca
Redlands Phone: 783-6927
Frequents Hospitality Lane
M}r,6. Jacob Sandetc.d
Maria Alverez 1839 Genevieve St)ceet
1505 Northpark Blvd. Phone: 883-5228
880-8880
Christine Larnery
341 Glenn Way
880-8488
Carla Castro
3031 Flores
880-8731
in the City of San Bernardino
WHFRFAt numerous studies have found chat tobacco smoke is a major contributor to indoor air
pollution;and that secondhand smoke kills 53,000 nonsmokers in the United States each year and,
WHFRFAS_ reliable studies, including the Environmental Protection Agency's report on passive
smoke, have shown that breathing sidestream or secondhand smoke is a significant health hazard;and
MLEEAS health hazards induced by breathing sidestream or secondhand smoke include lung cancer,
respiratory infection,decreased exercise tolerance,decreased respiratory function,bronchia-constriction,
and bronchospasm; and
WHEREAS the Surgeon General of the United States has advised nonsmokers to avoid exposure to
tobacco smoke wherever possible,and in particular, to protect infants and children from this smoke;
NOW THEREFORE. we as residents,request the city council to enact an ordinance that prohibits
smoking In all enclosed areas including restaurants,workplaces,and recreational facilities. We request that
the city council protect the public health and welfare and guarantee the right of nonsmokers to breathe
smoke-free air,and to recognize the need to breathe smoke-free air shall have priority over the desire to
smoke.
iv ,e
7 RE9 ADDRESS
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RESbW SfOvA E
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PRINT YOUR NAME CITY ZIP
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TORE l MUXNa AD6RM
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SIGNATURE RESIOErvCI ADDRESS
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TUBE RLSIDENCE ADDRESS
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P' ITiON FOX Cl.ist►lt•1 1NUOOK A.L'
in the City of San Bernardino
WHEREAS, numerous studies have found that tobacco smoke is a major contributor to indoor air
pollution;and that secondhand smoke kills 53,000 nonsmokers in the United States each year and,
WH REAS reliable studies, including the Environmental Protection Agency's report on passive
smoke, have shown that breathing sidestream or secondhand smoke is a significant health hazard;and
M3EAA5.health hazards induced by breathing sidestream or secondhand smoke include lung cancer,
respiratory infection,decreased exercise tolerance,decreased respiratory function,bronchia-constriction,
and bronchospasm; and
WHEREAS.the Surgeon General of the United States has advised nonsmokers to avoid exposure to
tobacco smoke wherever possible,and in particular, to protect infants and children from this smoke;
NOW THEREFORE_we as residents,request the city council to enact an ordinance that prohibits
smoking in all enclosed areas including restaurants,workplaces,and recreational facilities. We request that
the city council protect the public health and welfare and guarantee the right of nonsmokers to breathe
smoke-free air,and to recognize the need to breathe smoke-free air shall have priority over the desire to
smoke.
RESIDGNa ADDRESS
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S'C US004U ADDRESS
PRNVT CITY zr
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P7 LTIUM t"Uh k'"LAM lNlyUOK Al,
in the City of San Bernardino
WHF_RFAS numerous studies have found that tobacco smoke is a major contributor to indoor air
pollution;and that secondhand smoke kills 53,000 nonsmokers in the United States each year and,
WHEREAS. reliable studies, including the Environmental Protection Agency's report on passive
smoke, have shown that breathing sidestream or secondhand smoke is a significant health hazard;and
WHF_RFaS.health hazards induced by breaching sidestream or secondhand smoke include lung cancer,
respiratory infection,decreased exercise tolerance,decreased respiratory function,bronchia-constriction,
and bronchospasm; and
WHEREAS.the Surgeon General of the United States has advised nonsmokers to avoid exposure to
tobacco smoke wherever possible, and in particular,to protect infants and children from this smoke;
NOW THEREFORE. we as residents,request the city council to enact an ordinance that prohibits
smoking in all enclosed areas including restaurants,workplaces,and recreational facilities. We request that
the city council protect the public health and welfare and guarantee the right of nonsmokers to breathe
smoke-free air,and to recognize the need to breathe smoke-free air shall have priority over the desire to
smoke.
St-77 2
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Helping you breathe a little easier
QUESTIONS AND ANSWERS REGARDING
ELIMINATING SMOKING IN RESTAURANTS -
Why is it important to eliminate smoking in restaurants?
For waiters and waitresses, restaurants are a workplace. Although many employers have taken steps to protect
employees from secondhand smoke,waiters and waitresses are still exposed during theirworkday and still need
to be protected.
Ilow great a risk is secondhand smoke?
A recent study conducted by Dr. Stanton Glantz and Dr. William Parmley at the University of California, San
Francisco, determined that 53,000 nonsmokers die each year from secondhand smoke. The Environmental
Protection Agency has declared secondhand smoke to be a Class A Carcinogen—a carcinogen like radon,
asbestos,and benzine which is definitely known to cause cancer in humans and for which there is no safe level
of exposure. The U.S.Surgeon General,the National Institute of Occupational Safety&Health,and every other
agency that has investigated secondhand smoke has determined that it presents great health risks and exposure
should be avoided.
Are the health risks for employees in restaurants any greater than for employees in other workplaces? Y
The concentration of smoke in restaurants in significantly greater than in typical workplaces. The Environmental
Protection Agency's calculations of health risk assume seven workers per 1,000 square feet in the average
workplace,with two of the seven being smokers.In restaurants,the average capacity is 35 people per 1,000 square
feet,with 10 of them being smokers. Even with higher ventilation requirements, the concentration of smoke in
restaurants will be two to five times higher than in the typical workplace. Many nonsmokers have successfully
sued for workers' compensation benefits and the right to a smokefree workplace. In restaurants, many
nonsmoking employees have come down with smoking-related diseases as a result of theirworking environment.
In one case in Sauselito, a nonsmoking vegetarian waiter was awarded an$85,000 out-of-court settlement after
suffering a heart attack from exposure to secondhand smoke in the restaurant where he worked for five years.
Aren't nonsmoking patrons protected from secondhand smoke when they sit in nonsmoking sections?
They will be protected only if the smoking sections is in a separate room with a completely separate ventilation
system. Few restaurants are set up this way. Most smoking and nonsmoking sections are next to each other,and
air can move freely between them,carrying smoke with it. Ventilation systems can also carry smoke from room
to room even if the rooms are physically separated. The U.S.Surgeon General has stated that separate sections
do not eliminate the risk of exposure to secondhand smoke.
Restaurant owners claim that their current ventilation systems adequately protect nonsmokers. Is that
true?
No,itisn't. Restaurants are ventilated in accordance with standards established in the early 1980s by the American
Society of Heating,Refrigerating and Air Conditioning Engineers(ASHRAE)—standards which were heavily `
influenced by the tobacco industry. The ASHRAE standards treat secondhand smoke as an irritant rather than
a health risk. They are designed to remove the odor of smoke,but do not remove all of the cancer-causing agents. "
Tobacco smoke contains thousands of chemicals, many of which are colorless and odorless. Just because you
cannot see or smell smoke does not mean you are not at risk.
2530 San Pablo Avenue, Suite J • Berkeley, California 94702 • (415) 841-3032 / FAX (415) 841-7702
I 7
Couldn't restaurant owners simply improve their ventilation systems instead of going smokefree?
If restaurants are concerned about cost, this is the last thing they would want to try. To reach a level where the
risk of an employee contracting cancer is acceptable by federal standards (one chance in 100,000 of getting the
disease),the amount of ambient carcinogenic tar would have to be no higher than.75 microgram for every cubic
meter of indoor air. Since the average level of measurable in American restaurants is currently 202 micrograms
per cubic meter, ventilation effectiveness would have to be increased 270 fold to reach that level. This is
technologically impractical. Improving the effectiveness of ventilation systems is not cheap; the EPA estimates ,
it costs one dollar per square foot per year just to double ventilation performance. Thus, a 5,000-square-foot
restaurant would spend$5,000 each year(in 1990 dollars) to marginally improve air quality at a level far short
of a 270-fold improvement. An ordinance requiring stronger ventilation systems would bankrupt restaurants and
would be impossible to enforce. Remember, it costs nothing to prohibit smoking.
Restaurant owners claim that they would lose business under this ordinance, representing a great
economic hardship. Isn't that true?
There is no evidence that restaurant ordinances of this magnitude hurt business. Over twenty similar ordinances
have passed throughout the country. Aspen,Colorado implemented a 100%smokefree restaurant ordinance in
June of 1986. An independent study conducted by the Aspen Resort Association shortly thereafter found that
business improved after the ordinance went into effect. In San Luis Obispo, California, the local Chamber of
Commerce—which originally opposed its smokefrce restaurant ordinance—has now admitted that the ordinance
"has not hurt most local businesses." The city of Bellflower,California,analyzed sales tax data for the first full
quarter after their smokefree restaurant ordinance was implemented. They found that business in restaurants
increased compared to the previous months and the same quarter the year before. The city was also able to
determine that restaurants who claimed to lose business actually began to lose business before the ordinance went
into effect. Although restaurant owners fear that smokers will go to neighboring cities or stop dining out if
smokefree legsliation is adopted, only 21%of adult Californians are smokers, and a recent poll commissioned
by the California Restaurant Association found that 30%of all smokers prefer nonsmoking sections in restaurants.
Furthermore, several cities in the Bay Area have already adopted similar ordinances, and many others will be
introduced in the next few months,making it unlikely that smokers will travel to other areas to dine out. Any loss
of business from smokers is expected to be minimal,and will be offset by increased business from nonsmokers
who avoid smoky restaurants. All the evidence,includingevery independent,empirical study of 100%smokefree
restaurant.ordinances, shows-chat restaurants do not suffer as a result of these ordinances.
Aren't these ordinance expensive for cities to implement?
Smoking pollution control ordinances of all types have demonstrated to be easy and inexpensive for local health
departments or city officials to enforce. In fact,cities report that the newest 100%smokefree restaurant ordinances
are even easier to enforce because there is no ambiguity in how to implement smokefree policy. Furthermore,
to the extent that these ordinances may coincidentally reduce smoking in the community, these ordinances may
actually save ci ties money.The San Francisco Department of Public Health,using data provided by the California
Department of Health Services, determined that if a 100% smokefree ordinance reduced smoking in San
Francisco by only 1%(a conservative estimate),the City would save$2,347,152 each year that would otherwise
be spent on treating smoking-related diseases.
February 5, 1992
r
Iunderstand very well the response '
of the Pasadena restaurant owners _.
who are organizing against a pro-
posed city ordinance which would pro-
hibit smoking in Pasadena restaurants.
Three years ago I fought very hard to
defeat the Beverly Hills no-smoking or- 3
dinance. At that time I was president of
the Beverly Hills Restaurant Associa-
tion and along with many others I felt
that a 100 percent no-smoking policy in
Beverly Hills would prove a financial
hardship. Since Beverly Hills is essen-
tially a small island in the middle of
Los Angeles, many of us felt that our
customers would simply walk across
the street to L.A. instead of dining with
us.
We defeated that no-smoking ordi-
nance with major funding from the to-
bacco industry.
But times have changed. We have
new facts, new attitudes and new laws
regarding smoking. Today, it is illegal
to smoke on domestic u:g hts, yet smok-
ers fly across the country every day.
It's socially acceptable to ask someone
not to smoke near you.
When I learned that second-hand
smoke is a known carcinogen with no
safe level of exposure, and that air con-
ditioning simply recirculates it, I decid-
ed I did not want my family, my cus-
tomers or my employees to breathe to-
bacco smoke. I own Jacopo's restau-
rants, a full service Italian restaurant
chain with wine and beer service..My
restaurants are located in Beverly Hills,
Pacific Palisades, West Los Angeles and
Hollywood. My Hollywood location has
a full bar. Ten months ago I made all
four of my restaurants 100 percent no
smoking, including the bar and outdoor
patio area in my Pacific Palisades loca-
tion.
Before I did it, I was really nervous.
Was I going to destroy a business that
I've worked so hard to build?
These last 10 months have seen the
worst in the U.S. economy since the
Great Depression, with restaurants es-
pecially hard hit. Yet Jacopo's sales are
about the same as last year. I've had a
few guests upset by my policy, but most
of them, after hearing the reason why,
decided to stay. A very, very few leave.
Those who leave are far outnumbered
by the guests who tell me every day
that they love our smoke-free dining
and Jacopo's great food. The aromas
from the kitchen are not enhanced by
cigarette smoke. "
Restaurants that are afraid to become
smoke-free need to wake up and look
around. Last year the highest-rated res-
taurant in the Los Angeles area was
Matsuhisa in Beverly Hills. They are
100 percent no smoking. You can't get
into that place with a gun — forget
reservations. California Pizza Kitchen
and Carl's Jr. have become smoke-free,
and a whole host of other restaurants ,
as well.
I applaud the mayor of Pasadena and
the Pasadena Tobacco Control Coalition-
for their good sense and their willing-
ness to do the right thing. -.
BARRY FOGEL
Beverly Hills
n I
* ` city sAn
luis oB1.Vo
too 0
W
OFFICE OF THE MAYOR • 980 PALM STREET
Post OffiC9 Box 8100 • San Luls Oblapo,OA 83403.6100 • 8051649.7111
October 29, 1992
The Honorable Paul R. Soglin
Mayor of Madison, Wisconsin
210 Martin Luther King Drive
Milwaukee, WI 53703
Dear Mayor Soglln;
I recently learned that the City of Milwaukee is considering a comprehensive smoking
ordinance that, among other things, precludes smoking In restaurants, You may be
aware that the City of San Luis Obispo adopted a comprehensive Smoking Ordinance
nearly two years ago. Under the City's Ordinance, smoking is prohibited in all public
places, Including bars and restaurants. To the best of our knowledge, our Ordinance is
the strongest in the nation. As a result, I am extremely familiar with how emotional and
controversial taking this action can be,
Let me assure you that our City Council took its share of "heat" for adopting the
Ordinance, 1, for one, cast the sole dissenting vote. As a long-time businessman in this
community, I felt that adopting an ordinance this stringent would have a very negative
effect on our local economy, especially since the City relies so heavily on tourism. Once
the Initial controversy died down, however, I have to admit that with relatively little effort,
the Ordinance has been a complete success. Examples of our success include;
* Our community overwhelmingly supports the Ordinance. This is documented in
a poll conducted by local University students which revealed that nearly 75% of the
community supports the Ordinance.
* The Ordinance has not had a negative financial impact on our hospitality industry.
The Executive Director of our local Chamber of Commerce has gone on record
stating "that the Ordinance has not harmed local business", In addition, an
analysis of sales tax receipts shows that receipts actually rose by 7.6% for
restaurants and hotels in the first half of 1991 (after the Ordinance was adopted)
when compared to the first half of 1990 (prior to adoption of the Ordinance).
* Enforcement of the Ordinance, has gone extremely smoothly, Support and
cooperation from the public and business community has been outstanding, This
is evidenced by the fact that the City has only issued a total of six citations over
the last two years,
Mayor Paul R. Soglln
City of Madison Page 2
October 29, 1992
* Costs to implement the Ordinance has been minimal. The City has spent
approximately $3,000 on materials (no smoking signs, etc.) and brochures, Staff
time Is limited to following up on complaints and responding to inquiries (this
equates to approximately four hours per month).
We attribute a lot of our success with the Ordinance to two crucial elements: creating a
fair and equitable enforcement policy that relies on voluntary compliance form the
community (copy attached) and working closely with our bars and restaurants prior to
ordinance implementation to make sure they understand their role In the enforcement
process. i urge you to contact Deb Hossli at (805)781-7151 if you need additional
Information on the City's experience with implementing the Ordinance.
In conclusion, the City Is very proud of Its Smoking Ordinance. We feel we have struck
a fair balance between protecting public health and maintaining a vital hospitality industry.
Good luck with your efforts.
Sincerely,
CITY OF SAN LUIS OBISPO
RON DUNIN
Mayor
RD,DH:ss
Attachments
Af n,0r4WW,0_�(Of 0 4 10Wff
Helping you breathe a little easier
THE ECONOMIC IMPACT OF 100% SMOKEFREE RESTAURANT ORDINANCES
There is no data from any city that has passed a 100%smokefree restaurant ordinance to support tobacco industry
claims that such ordinances lead to a decrease in restaurant business. Sales tax data from cities with smokefree
ordinances show that these ordinances have no negative economic impact on restaurants.
•:• An analysis of sales"tax receipts from the California cities of San Luis Obispo, Lodi,Bellflower and Beverly ,
IIills found that 100%smokefree restaurant ordinances have had no effect on restaurant sales,either in absolute
terms or in comparison with similar cities without a 100%ordinance. If anything, the presence of a smokefree
restaurant ordinance slightly increased the share of total retail sales that went to restaurants. (Glantz and Smith, -
"The Effect of Ordinances Requiring Smokefree Restaurants on Restaurant Sales in California"University of California San
Francisco, Institute for Health Policy Studies, March, 1992)
•:• Bellflower,CA: An independent tax revenue consultant analyzed City sales tax receipts for the first full quarter
with the 100% smokefree restaurant ordinance in effect. Sales for dine-in restaurants increased slightly from
$3,934,000 to$4,290,000 compared to the prior year. This slight increase matched the trends observed for other
municipalities in the area. (Hinderliter, de Llamas and Associates, Glendora, CA, November 8, 1991)
San Luis Obispo,CA: Restaurant and hotel sales tax receipts for the first two quarters of 1991 (after adoption
of the ordinance)were higher by 7:6%when compared to sales tax receipts for this same category during the first
two quarters of 1990(prior to adoption of the ordinance),contrary to Tobacco Institute claims of a 26%decrease
in restaurant sales after the 100% ordinance went into effect. The local Chamber of Commerce has publicly
confirmed that the ordinance"has not harmed most local businesses." A poll of San Luis Obispo residents,taken
after the ordinance was implemented, found that 75%of residents supported the ordinance—including 37.5%of
smokers. (San Luis Obispo City Council correspondence, January 29, 1992 and March 9, 1992)
•:• Beverly IIills,CA: The tobacco industry convinced the City Council to weaken its 100%smokefrec restaurant
ordinance on the basis of unsubstantiated claims that business dropped 30%because of the ordinance. A recent
study by researchers at the University of California,San Francisco found that,contrary to industry claims, there
was no drop in restaurant sales during the time the 100%ordinance was in effect. (Glantz and Smith, "The Effect
of Ordinances Requiring Smokefree Restaurants on Restaurant Sales in California"University of California San Francisco,
Institute for Health Policy Studies, March, 1992)
•:• Aspen,CO: Monthly studies conducted by the Aspen Resort Association found that total retail sales, including
restaurants, actually increased after the City's 100%smokefrec ordinance went into effect. A study conducted
by the Aspen/Pitkin Environmental Health Department found broad support for the ordinance among restaurants
and retailers,and"no negative effect inbusiness whatsoever." (Aspen Resort Association,'Business Update,"October
1986 through March 1987;Aspen/Pitkin Environmental Health Department, November 29, 1990)
❖ The California Cafe Restaurant Corporation, after implementing a nonsmoking policy in its 11 restaurants
throughout California, receives written and verbal comments running at least 10 to 1 in favor of the policy. The ••
President reports that the nonsmoking policy has had a positive effect ontheirbusiness. (Robert Freeman,President,
California Cafe Corporation, correspondence, February 17, 1992)
In 1987, of the 28 percent of Americans who smoked, 29 percent chose to sit in the nonsmoking section of a
restaurant. (1987 Gallup survey for the National Restaurant Association)
3192
2530 San Pablo Avenue, Suite J • Berkeley, California 94702 • (415) 841-3032 / FAX (415) 841-7702
MAR 3 0
A&I S
OGR� ME
INSTITUTE FOR HEALTH POLICY STUDIES-UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
i
. The Effect of Ordinances Requiring Smoke Free Restaurants
on Restaurant Sales in California
Stanton A. Glantz, PhD
Lisa R. A. Smith, BA
March, 1992
Y
The Effect of Ordinances Requiring Smoke Free Restaurants
on Restaurant Sales in California
Stanton A. Glantz, PhD
Lisa R. A. Smith, SA
Institute for Health Policy Studies
School of Medicine
University of California, San Francisco
1388 Sutter Street, 11 th Floor
San Francisco, CA 94109
March, 1992
Supported by funds provided by the Cigarette and Tobacco Surtax Fund of the State of California through the
Tobacco-Related Disease Research Program of the University of California (Award 1RT 520). Lisa Smith's
address is Regional Tobacco Prevention Center, 909 12th Street, Suite 110, Sacramento, CA 95814. Address
correspondence to Dr. Glantz at: Box 0124, University of California, San Francisco, CA 94143; phone (415)
476-3893.
EXECUTIVE SUMMARY
The potential effect of local ordinances requiring smoke free restaurants on
restaurant revenues is an important consideration for restaurateurs themselves and cities
which depend on sales tax revenues to provide city services.
To assess the effects of such ordinances on restaurants, we obtained data from the
California State Board of Equalization on taxable restaurant sales from January 1, 1986,
through the June 30, 1991, for the communities of Bellflower, Beverly Hills, Lodi, and San
Luis Obispo, where 100% smoke free restaurant ordinances were in force, as well as similar,,,.
communities (Lakewood, Los Angeles, Woodland, and Atascadero) where no such
ordinances were in effect.
These data were analyzed using a multiple linear regression econometric model,
including year (for the underlying time trend), quarter (for seasonal adjustment) and a
variable to indicate whether or not an ordinance was in force at the time.
We analyzed:
• Total restaurant sales
• Restaurant sales as a fraction of total retail sales
• Restaurant sales in cities with smoke free restaurant ordinances versus a
comparison city that had no such ordinance.
This analysis showed: --
• The presence of a 100% smoke free restaurant ordinance had no significant
effect on total restaurant sales in any community.
• The presence of a 100% smoke free restaurant ordinance was associated with
a small, but statistically significant, increase in the fraction of total retail sales
that went to restaurants. (Restaurant sales increase from about 13% to about
14% of total retail sales when a smoke free restaurant ordinance was in
force.)
• The presence of a 100% smoke free restaurant ordinance had no significant
effect on the ratio of restaurant sales in communities with such an ordinance
compared with matched control communities which had no such restrictions.
• The effects of a 100% smoke free ordinance were similar on all categories of
restaurants, defined by the kind of alcoholic beverages (if any) were served.
There is no evidence to support the common claim, first made in Beverly Hills, that
smoke free restaurant ordinances reduce business by 30%. The overall conclusion from
these data is that 100% smoke free restaurant ordinances do not adversely affect restaurant
sales within a community or lead to a shift in patronage to restaurants in communities with
no such ordinances. If anything, 100% smoke free restaurant ordinances make restaurants
more competitive for retail sales dollars.
3
� INTRODUCTION
As the evidence that environmental vvhat if
1.2,3,4.5
tobacco smoke endangers nonsmokers _
has accumulated, more and more -*�&ss--*cd law
communities have restricted or eliminated .
smoking in public places and work places. took away,
Recently,several communities have enacted
legislation mandating 100% smoke .free ���
restaurants. The health benefits of such of
legislation is obvious: it protects the public 3u
and,particularly,restaurant employees from 8
the toxic chemicals in second hand tobacco •
smoke. Such legislation, however, is not in
the interests of the tobacco industry
because creation of smoke free restaurants
hi(hspyrns 13'`�llr si1`X}.Q1M1tRxUR A tYTt]Ur" tKU tyO�flbitY fNY16Uh .
is a highly visible statement that tobacco ��lat:ytxs.«�iwnrr+rN:�i.,in 1:"%MYZMtrfaugya�r '#*toW-
1lSfillr7�M;' Pt7KM MYMN Cuttortxr�9
YwT use is not longer socially acceptable.' This ,,"P" nt ;;; ;R„ M ''""
(u M•it.—W orTV.[i�+-hnve Write us AM n'd rend).tw
declining social acceptability of tobacco peT*nctd mwh beru.Be*"a Wwra(40nc.Wraetb tl r►,ttra„t
rm al,Inik�Aax+W►ti ttiftykC to kk rrtY Kroup.luwfbu�M revel W4 tons 1Vt11
helps smokers quit and discourages Hpih.n�a.aent�wrretxp"If3 rtY* c neut�t 9«tr+m,cun,.cm,.
slat d tit 2 rtttOkW� 2.i WO"s W..+tiP. all Y-W non-
Sftt't the resl ne.w.thn.41.In IN v+..k.ra alL.AaQ et tt hr tP Ytat IttNNt
nonsmokers from starting,resulting in a loss _r;&J"pr2l;LI n.t20 Cq 01-Y—'VA"M%.Wi
JkAT,.t of tt,r u.s pCou;i• "`. '�"� eta po•vmwatt t""p
in sales and profits to the tobacco industry. ��n t YISa u
As a result, the tobacco industry has
invested considerable resources in opposing Figure 1. Advertisement run by the Tobacco
local ordinances mandating smoke free Institute in restaurant industry trade journals
restaurants, often working through claiming that smoke free restaurant ordinances
organizations established or financed by the reduce business by 30% based on the experience
tobacco industry such as the Beverly Hills in Beverly Hills.
Restaurant Association, Restaurants for a
Sensible Voluntary Policy on Smoking (RSVP), Californians for Fair Business Policy, or the
California Business and Restaurant Alliance.' The industry uses these organizations to
mobilize restaurants against proposed ordinances using the argument that requiring smoke
free restaurants will be bad for business. This strategy achieved its first notable success in `
1987, when the tobacco industry convinced the Beverly Hills City Council to repeal the first
100% smoke free restaurant ordinance in California on the basis of claims that business
dropped 30% because of the ordinance.' This claim has been a continuing theme in the
tobacco industry's campaign against smoke free restaurant ordinances (Figure 1). The
tobacco industry has also been successful in convincing local restaurant associations to
oppose smoke free restaurant ordinances on the basis of concerns over the effects on
business.'
There is now enough information available to conduct an objective econometric
analysis of the effects of smoke free restaurant ordinances. In addition to Beverly Hills
(which amended its ordinance to eliminate the 100% smoke free requirement), the
4
California cities of Bellflower, Lodi, and San Luis Obispo. have had such 100% smoke free
restaurant ordinances in force long enough to assess their effects based on reported taxable
sales data available from the California State Board of Equalization.' Analysis of total
restaurant sales, individual categories of restaurant sales, restaurant sales as a fraction of
" total retail sales; and restaurant sales in cities with 100% smoke free restaurant ordinances
compared to similar cities which do not have ordinances show no negative effects on
business. If anything, smoke free restaurants are slightly beneficial for business by increasing
the fraction of total retail sales that go to restaurants.
F77Table 1. Cities with Smoke Free Restaurant Ordinances
City Smoke Free Restaurant Comparison City
Ordinance in Effect
Beverly Hills April 1987 to August 1987 Los Angeles
Bellflower March 1991 on Lakewood
Lodi November 1990 on Woodland
San Luis Obispo August 1990 on Atascadero
METHODS
Data were obtained on taxable restaurant sales and total retail sales from quarterly
reports available from the California State Board of Equalization' from the first quarter of
1986 through the second quarter of 1991 for the four communities which had smoke free
restaurant ordinances in force during this period as well as similar communities which had
no such ordinances in force (Table 1). Data were recorded for"Eating and Drinking Places"
and "Total Retail Sales." In addition, the restaurant data were broken out by type of
restaurant, "Eating Places, No Alcohol (Code 24)," "Eating Places, Beer and Wine (Code
35)", and 'Bating Places, All Types of Liquor (Code 36)." These data appear in the
Appendix tables A-1 and A-2.
In addition to analyzing the sales figures (S), we also computed the fraction (F) of
total retail sales at restaurants by computing
F = Restaurant sales
Total retail sales
If an ordinance adversely affects restaurants, this fraction should drop when the ordinance
is in force. We also compared restaurant"sales in cities with ordinances to comparable cities
without ordinances, by computing the ratio
5
C __ Restaurant sales in community with ordinance
Restaurant sales in community without ordinance
If an ordinance adversely affected sales, then this;ratio should drop. Both F and C should
provide better measures of the effects of an ordinance than raw sales (S) because the
comparisons automatically take quarter-to-quarter changes in economic conditions into
account.
These time series data were analyzed with a linear regression econometric model."
The basic model is
Y - PO + Fitt + P2Q2 + P3Q3 + P4Q4 + PLL
where y is the dependent variable (S, F, or C), t is time (i.e., year) to represent the
underlying secular trend, Q,, Q,, and Q, are dummy variables to represent seasonal variation
with the first quarter being the reference condition, and L is a dummy variable that indicates
whether or not a smoke free restaurant is in force. For example, for the first quarter of
1986 t=1986 and for the second quarter of 1986 t=1986.25. The estimate of the coefficient
Q, quantifies the annual rate of increase (or decrease) in the dependent variable, y, each
.» year. The dummy variable for the seasonal trend for the second quarter, Q, is defined as
1 if second quarter
•• Q2 0 otherwise
and Q, and Q, are defined analogously. The coefficient 62 quantifies how much the second
quarter is above the underlying secular trend. The dummy variable L quantifies the
presence of a smoke free restaurant ordinance according to
0 if no ordinance
L = { 1/3 if ordinance in force for 1 month of quarter
2/3 if ordinance in force for 2 months of quarter
1 if ordinance in force for entire quarter
The coefficient 6,,quantifies the magnitude of the effect of the ordinance on the dependent
variable. For example, if an ordinance reduced restaurant sales by 30% (as was claimed for
Beverly Hills), the estimate for QL with fraction of total retail sales that are from restaurants
(F) would be -.300 and significantly different from zero.
In addition to computing the parameter estimates,we computed the variance inflation
factors for each variable to assess multicollinearity and the Durbin-Watson statistic to test
for autocorrelation among the residuals. A large variance inflation factor would indicate that
the parameter estimates are uncertain and could lead us to miss an effect. The variance
inflation factors were always well below 2, indicating no problem. In a few cases, the
6
Durbin-Watson statistic was significant (smaller than dL=0.86 for n=22 data points, P=.05),
indicating a significant autocorrelation among the residuals. When this situation exists, the
parameter estimates can be unreliable. In the few cases in which this situation occurred, the
regression model above was supplemented with a first order autoregressive model for the
residuals"
rk = �rk-i + Ek
where rt is the residual for quarter k for the original regression model, 0 is a parameter to
be estimated, and e, is an independent random error term. (We also investigated a second
order autoregressive model for the residuals, but doing so did not significantly improve the
quality of the fit.) In all cases, this supplement produced acceptable values of the Durbin-
Watson statistic for the original problem; When this autoregressive model was used, it is
indicated in the tables summarizing the results.
r In addition to analyzing data for each city separately, we also pooled all the data on
restaurant sales as a percentage of total retail sales for all eight cities (4 with ordinances 4
without no ordinance)for the entire 5 year period in a single analysis, including 7 additional
dummy variables to allow for between-city differences in the mean values of the fraction of
total retail sales going to restaurants.
All data were fit with this model using Minitab Version 8.2. A change is considered
statistically significant when P<.05.
RESULTS
Table 2 summarizes the results of the statistical analysis for total restaurant sales (S),
total restaurant sales as a fraction of all retail sales (F), and total restaurant sales in cities
with ordinances compared with the matched comparison cities (C). The first column in the
table is the mean value observed from 1986 to the second quarter of 1991 to provide a
comparison with the magnitude of the change associated with the ordinance. The second
- column is the estimate of the effect of the smoke free restaurant ordinance, as quantified
with the coefficient ML together with its standard error (an estimate of the precision of the
estimate), the third column is the associated P value to test the hypothesis that PL is...
significantly different from zero. The fourth and fifth columns are the multiple correlation
coefficient associated with the entire regression model and the associated P value for the
entire model. The last column is the Durbin-Watson statistic for the regression model
(including the autoregressive component, when appropriate).
7
Beverly Hills
(Smoke free ordinance in solid points)
•
$40
$30
y
$20 � i TI claim
E
$10
$0
1986 1987 1988 1989 1990 1991 y
Year
Figure 2. The 100% smoke free restaurant ordinance in force in Beverly Hills did not
reduce sales by 30%, as the tobacco industry claimed; it had no significant effect on
revenues.
Smoke free ordinances have no statistically significant effect on total restaurant sales
or total restaurant sales in cities with ordinances compared to cities without ordinances.
There is some evidence (P=.025) that restaurants took a greater share of total retail sales
in Bellflower after the smoke free restaurant ordinance went in to force (with restaurants'
share of total retail sales increasing by 2.6% from 12.8% to 15.6%). One ought not make
-- too much of this result, however, because one statistically significant coefficient out of 13 is
not far from what one would expect by chance if there was no true effect.
Table 2 also provides strong evidence that the presence of a smoke free restaurant
ordinance slightly but significantly (P<.001) increases the restaurants' share of total retail
sales (by increasing by 1.2% from an,average of 12.7% to 13.9%).
Figure 2 shows the sales data for Beverly Hills. Beverly Hills is a particularly
important case because the ordinance was put into force, then the 100% smoke free
requirement was repealed several years ago. This situation allows us to assess the effect of J
putting the ordinance into force as well as removing it. The solid points in Figure 2 show
quarters in which the ordinance was in effect. Had sales dropped by 30% as asserted by
tobacco interests (Figure 1), the curve would have dropped by 30% (as indicated by the
dashed lines in Figure 2). Figure 2 shows that no such drop in sales occurred. The
ordinance had no significant effect on restaurant business (Table 2).
8
Table 2. Effect of Smoke Free Restaurant Ordinances on Total Restaurant Sales
Effect of Ordinance Model
City Mean Change, Q, P R2 P dt
Total Sales, S (thousands of dollars)
Bellflower 9,723 -1103 ± 811 .192 .736 .000 1.72
Beverly Hills' 25,671 2013 ± 1849 .294 .210 .568 1.11
Lodi 8,910 -166 ± 320 .612 .892 .000 1.17
San Luis Obispo 135650 -346 ± 763 .657 .792 .000 2.72
Fraction of Total Retail Sales, F (percent)
Bellflower 13.0 2.1 ± 1.0 .046 .510 .030 1.85
Beverly Hills 12.6 -.03 ± 0.97 .974 .623 .005 1.39
Lodi 11.8 0.3 ± 0.6 .631 .499 .035 2.30
San Luis Obispo 12.8 1.3 i- 0.7 .082 .551 .016 2.55
All Combined 12.7 1.1 ± 0.4 .002 .782 .000 1.93
Ratio of Sales with Comparison City, C (percent)
Bellflower 43.1 3.6 ± 4.9 .467 .128 .793 1.35
Beverly Hills 4.0 -.08 ± 0.30 .806 .271 .358 1.16
Lodi 150.0 7.9 ± 11.6 .506 .500 .034 1.71
San Luis Obispo 295.1 1.26 ± 27.1 .963 .128 .792 2.69
'Fit with autoregressive model of residuals.
'Durbin-Watson statistic.
Figure 3 presents the data on total sales for the other three cities with smoke free.
restaurant ordinances. As in Figure 2, the quarters in which.the ordinances were in effect
are shown as solid points. The ordinances had no significant effect on restaurant business
(Table 2).
We also analyzed the effects of smoke free restaurant ordinances on the three
different types of restaurants described in Methods (No Alcoholic Beverages, Beer and
Wine, All Types of Liquor). The results data appear in Appendix Tqbles A-3 through A-6.
9
Restaurant Sales
(Smoke free ordinance in solid points)
$40
r $30
C
C
$20
.A'-O`
$0
1986 1987 1988 1989 1990 1991
is Bev Hllls --0— SLO — L�— Lodi --�' Ball awer
—ik— Bw Hltle Or —♦— SLO Ord —�— Lodl Ord —.--• Belll Ord
Figure 3. Smoke free ordinances did not significantly affect total sales in any of the four
communities studied.
These results demonstrate a marginal positive effect of ordinances on Bellflower restaurants
that serve beer and wine as a fraction of total retail sales, a marginal positive effect on
Bellflower restaurants that serve liquor in comparison with similar restaurants in Lakewood,
and a marginal negative effect on.total sales of Lodi restaurants that sell beer and wine total
sales. Given the large number of statistical tests that were conducted, the lack of a
consistent effect in different communities, and the small sizes of the effects, these results
may be statistical artifacts. The overall conclusion from the data on different types of
restaurants is that smoke free restaurant ordinances do not have different effects on
different categories of restaurants.
LIMITATIONS OF THIS STUDY
There are three limitations of this study which should be kept in mind. First, most
of the smoke free restaurant legislation has only been in force for a few quarters for which
data were available, mostly at the end of the observation period. It would be more desirable
to have had a longer series of observations. The fact that the Beverly Hills 100% smoke
free restaurant ordinance was in force then repealed helps mitigate this problem, since we
have a long period of observation both before and after the Beverly Hills ordinance was in
force. Had the ordinance affected business,we would have seen changes from the long-term
sales trend both when the ordinance went into force and when it was repealed. We
observed no such changes (Figure 2). Moreover, the fact that we failed to detect a
significant fall off in business in 1991 despite generally poor economic conditions adds
10
confidence to the general conclusion that smoke free restaurant ordinances are not bad for
business. Second, Los Angeles is much larger and more diverse than Beverly Hills, so may
not have been the best comparison community. We selected Los Angeles because of its
proximity to Beverly Hills. Third, and less important, the State Board of Equalization
considers bars and restaurants that serve all forms of alcohol in the same category (Code
36), and all ordinances except San Luis Obispo exempt bars. This situation will reduce the
sensitivity of the detailed analysis in this one subgroup. The presence of bars in Code 36
should not, however, introduce significant errors in the analysis of the total data (in Table
2) because Code 36 (and bars within that category) make up a small fraction of total sales.
CONCLUSIONS
Based on data on restaurant sales obtained from the California State Board of
Equalization, there is no evidence that 100% smoke free restaurant ordinances have any
effect on restaurant sales, either in absolute terms or in comparison with similar cities that
have no such health and safety requirements. If anything, the presence of a smoke free
restaurant ordinance slightly increases the share of total retail sales that go to restaurants.
11
REFERENCES
1. Centers for Disease Control Office on Smoking and Health. The Health
Consequences of Involuntary Smoking. Rockville, Md: U.S. Dept. of Health and
Human Services, Public Health Service, Centers for Disease Control, Center for
Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;
1986.
2. Committee on Passive Smoking. Environmental Tobacco Smoke. Washington, D.C.:
National Academy Press; 1986.
3. Environmental Protection Agency. Health Effects of Passive Smoking. Assessment of
Lung Cancer in Adults and Respiratory Disorders in Children. Washington, DC:
Environmental Protection Agency; 1990. Publication EPA 600/6-90/006A.
4. Glantz SA, Parmley WW. Passive smoking and heart disease. Circulation 1991;83:1-
12.
5. Steenland K. Passive smoking and the risk of heart disease. JAMA 1992;267:94-99.
6. Roper Organization. Public Attitudes Toward Cigarette Smoking and the Tobacco
Industry. Prepared for the Tobacco Institute; May 1978.
7. Samuels B, Glantz S. The politics of local tobacco control. JAMA 1991;266:2110-
2117.
8. Golden Gate Restaurant Association. Press Alert and Fact Sheet: San Francisco's
Hospitality Industry Faces Smoking Ban. February 17, 1992.
9. California State Board of Equalization. Taxable Sales in California (Sales and Use
Tax) Table 5 (quarterly reports). Y
10. W. Mendenhall, T. Sincich. A Second Course in Business Statistics: Regression
w. Analysis. Chapter 9: Time Series Modelling and Forecasting. San Francisco: Dellen '
�• Publishing Company, 1989.
12
APPENDIX
Table A-1. Restaurant and Total Retail Sales for Cities with Smoke Free Restaurant
Ordinances and Comparison Cities.
Table A-2. Restaurant Sales by Type of Restaurant for Cities with Smoke Free
Restaurant Ordinances and Comparison Cities
Table A-3. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in Bellflower
Table A-4. Effect of Smoke Free Restaurant Ordinance on • Different Types of
Restaurants in Beverly Hills
Table A-5. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in Lodi
Table A-6. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in San Luis Obispo
13
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Table A-3. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in Bellflower
Type of Effect of Ordinance Model
Restaurant Mean Change, aL P R2 P dt
Total Sales, S (thousands of dollars)
No Alcohol 61313 -229 ± 1124 .841 .489 .040 2.40
Beer and Wine 1,604 118 ± 200 .563 .351 .185 1.85
Liquor 1,680 5 ± 266 .986 ,251 .411 1.52
Fraction of Total Retail Sales, F (percent)
No Alcohol 8.3 1.9 ± 1.3 .163 386 .131 2.36
Beer and Wine 2.2 .7 ± .3 .030 .457 .060 1.41
Liquor 2.2 .6 :t .4 .105 .328 .226 1.59
Ratio of Sales with Comparison City, C (percent)
No Alcohol 63.4 7.4 -+ 11.1 .514 .196 .578 2.58
Beer and Wine 61.6 1.2 ± 10.1 .226 .445 .069 1.74
Liquor 25.0 10.1 ± 4.0 .024 .461 .057 2.04
tDurbin-Watson statistic.
18
Table A-4. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in Beverly Hills
Type of Effect of Ordinance Model
Restaurant Mean
Change, Q, P RZ P d'
Total Sales, S (thousands of dollars)
No Alcohol' 3,594 505 423 .251 .565 .018 1.38
Beer and Wine 4,593 403 ± 707 .576 .066 .945 2.41
Liquor 17,915 -543 ± 830 .522 .525 .024 1.28
Fraction of Total Retail Sales, F (percent)
No Alcohol' 1.7 0.2 ± 0.2 .360 .613 .008 2.05
Beer and Wine 2.3 0.2 ± 0.4 .570 .404 .109 2.10
Liquor 8.8 -0.4 ± 0.5 .426 .841 .000 1.35
" Ratio of Sales with Comparison City, C (percent) '
No Alcohol' 1.2 0.2 ± 0.1 .272 .474 .062 1.43
Beer and Wine 3.5 0.3 ± 0.5 .576 .363 .165 2.33
Liquor 7.9 -0.3 ± 0.4 .497 .375 .147 2.01
'Fit with autoregressive model of residuals.
'Durbin-Watson statistic.
19
Table A-5. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in Lodi
Type of Effect of Ordina Model
Restaurant Mean
Change, g, nce P R? P dt -•
Total Sales, S (thousands of dollars)
No Alcohol' 4,458 -105 ± 134 .446 .869 .000 1.58
Beer and Wine 2,638 -354 ± 142 .024 .793 .000 2.64
Liquor 1,814 101 ± 218 .648 .162 .688 1.05
Fraction of Total Retail Sales, F (percent)
No Alcohol 5.9 0.4 ± 0.3 .267 .736 .000 1.53
Beer and ,Vine 3.5 -0.3 ± 0.3 .338 .254 .404 2.19
Liquor 2.4 0.2 ± 0.3 .359 .402 .112 1.43
Ratio of Sales with Comparison City, C (percent)
No Alcohol 154.0 8.5 ± 16.7 .617 .280 .334 1.12
Beer and Wine 174.9 -6.4 ± 22.2 .778 .360 .169 .94
Liquor 124.5 22.0 ± 28.2 .447 .523 .025 1.32
E Fit with autoregressive model of residuals.
rbin-Watson statistic.
20
Table A-6. Effect of Smoke Free Restaurant Ordinance on Different Types of
Restaurants in San Luis Obispo
Type of Effect of Ordinance Model
Restaurant Mean
Change, AL P RZ P dt
Total Sales, S (thousands of dollars)
No Alcohol 4,296 -338 862 .700 .250 .415 2.70
Beer and Wine' 5,010 -421 ± 223 .078 .753 .000 1.68
Liquor 4,137 -514 ± 518 .336 .529 .023 3.50 "
Fraction of Total Retail Sales, F (percent)
No Alcohol 4.1 0.4 ± 0.8 .634 .372 .151 2.56
Beer and Wine 4.7 -0.3 ± 0.3 .309 .687 .001 .91
Liquor 3.9 .02 ± .49 .975 .358 .173 3.54
Ratio of Sales with Comparison City, C (percent)
No Alcohol 266.8 -21.2 ± 48.6 .668 .303 .280 2.37
Beer and Wine 307.6 -17.4 ± 26.1 .515 .174 .650 2.16
Liquor 999.3 -26.5 -+ 202.6 .897 .430 .082 1.76
'Fit with autoregressive model of residuals.
tDurbin-Watson statistic.
21
s •
SMOKING AND RESTAURANTS:
A GUIDE FOR POLICY-MAKERS
Michael Siegel, M.D., M.P.H.
UC Berkeley/UCSF Preventive Medicine Residency Program
American Heart Association, California Affiliate
Alameda County Health Care Services Agency, Tobacco Control Program
September, 1992
� T
TABLE OF CONTENTS
ExccutiveSummary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . 1
Chapter 1: Health Effects and Public Health Impact of Involuntary Smoking . . . . . . . . . . . . . . . . 3
Chapter 2: Environmental Tobacco Smoke Exposure in Restaurants . . . . . . . . . . ... . . . . . . . . . . 10
Chapter 3: Health Effects of Environmental Tobacco Smoke Exposure in Restaurants . . . . . . . . . 15
Chapter 4: Smoking in Restaurants: The Legal Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Chapter 5: Economic Impact of 100% Smoke-Free Restaurant Ordinances . . . . . . . . . . . . . . . . . 26
Chapter 6: Analysis of Possible Regulatory Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chapter 7: Cities that have Adopted 100% Smoke-Free Restaurant Ordinances . . . . . . . . . . . . . 36
Chapter 8: Arguments Against 100% Smoke-Free Restaurant Ordinances . . . . . . . . . . . . . . . . . . 37
Chapter 9: Summary Fact Sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
EXECUTIVE SUMMARY
I. HEALTH EFFECTS AND PUBLIC HEALTH IMPACT OF INVOLUNTARY SMOKING
■ Livoluntary smoking causes:
♦ Increased frequency of cough and wheezing in children;
♦ Increased rates of pneumonia, bronchitis and other respiratory illnesses in
children;
♦ Reduced lung function and lung growth in children;
♦ Increased rates of chronic ear infections in children;
♦ Increased risk of heart disease in adults;
♦ Increased risk of lung cancer in adults;
♦ Increased risk of other cancers in adults;
♦ Exacerbation of symptoms in adults with chronic obstructive lung
disease;
♦ Exacerbation of symptoms in persons with asthma; and,
♦ Exacerbation of symptoms in adults with heart disease.
• Environmental tobacco smoke is a class A carcinogen - a substance known to
cause cancer in humans for which there is no safe level of exposure.
• The best estimate of involuntary smoking-related mortality in the United States
is 53,000 deaths per year: 37,000 from heart disease, 3,700 from lung cancer, and
12,000 from other cancers.
• Involuntary smoking is the third leading cause of preventable death, behind
only active smoking and alcohol.
• The cancer mortality from involuntary smoking alone exceeds the combined
mortality from all regulated environmental carcinogens.While involuntary smoking
is the number one cause of environmental cancer, it is essentially unregulated.
i
H. ENVIRONMENTAL TOBACCO SMOKE EXPOSURE IN RESTAURANTS
• Restaurant environmental tobacco smoke (ETS) exposure is about 3-5 times higher
than typical workplace exposure.
• Restaurant employees' ETS exposure is about 8-20 times higher than domestic
exposure.
• The most heavily exposed restaurant workers inhale the benzo(a)pyrene
equivalent of actively smoking 11h to 2 packs of cigarettes per day.
.■ Restaurant air causes gene mutations at a rate 10-100 times higher than previously
measured urban outdoor and indoor air.
• The mutagenic potency of restaurant air is 5-10 times that of "high-risk"
industrial workplace air.
• Heavily exposed restaurant workers have levels of carcinogens in their blood
2-3 times higher than persons with typical ETS exposure, and have higher levels of
mutagenicity in their urine.
• Restaurant employees are therefore the , occupational group most heavily
exposed to ETS and most likely to suffer adverse health effects due to ETS
exposure.
III. HEALTH EFFECTS OF ETS EXPOSURE IN RESTAURANTS
• In California, waitresses have the highest mortality of any female occupational
group. Compared to all other women, they have almost 4 times the expected lung
cancer mortality and 21h times the expected heart disease mortality rate.
• Preliminary evidence suggests that waiters and waitresses have about a 50-
90% increased risk of lung cancer that is most likely attributable to restaurant
tobacco smoke exposure. Thus, exposure to ETS at work makes restaurant
workers 11h to 2 times as likely to die from lung cancer as they would otherwise be.
• Although not yet studied, the morbidity and mortality of restaurant workers
from heart disease attributable to restaurant ETS exposure is expected to be even
more significant than for lung cancer.
' ii
IV. SMOKING IN RESTAURANTS: THE LEGAL SITUATION
• Restaurant employers are required, under common law, to provide a smoke-free
work environment for employees. In addition, under Federal and state law, they
must protect employees who are especially sensitive to smoke by providing a
smoke-free work environment. When they fail to do so, employees have three
potential remedies:
1. To collect workers' compensation benefits for ETS-induced injury;
2. To file suit against the employer for damages due to failure to protect
from the hazards of ETS, if the injury is ruled not to be within the scope
of workers' compensation; and,
3. To terminate employment for fear of health damage from ETS, and collect
unemployment compensation benefits.
• Claims in each of these three areas have been made by employees affected by
ETS at work, upheld by the courts, and have resulted in numerous large awards or
settlements. Employer liability for ETS-induced worker injury will become an
increasingly important issue for employers. Potential liability can be eliminated by
legislative action to protect nonsmoking employees from the hazards of ETS.
V. ECONOMIC IMPACT OF 100% SMOKE-FREE RESTAURANT ORDINANCES
• Based on the best available evidence, 100% smoke-free ordinances have no
significant impact on restaurant sales.
• Studies that found a decrease in restaurant sales in Beverly Hills and Bellflower
had serious methodologic flaws, and are invalid.
• The use of anecdotal evidence and restaurant surveys is inherently biased and
inappropriate in analyzing the economic impact of smoke-free ordinances; it
does not provide information useful in evaluating this issue.
• Public policy-makers have been misled about the economic impact of restaurant
smoking ordinances, by studies based on invalid evaluation approaches. Before
being considered seriously, evidence should be evaluated on criteria which include
the use of actual sales tax data, inclusion of all data points before and after
implementation of an ordinance, the use of regression or other statistical methods
to control for trend and fluctuation in the data, and appropriate control for overall
economic trend.This will help ensure that public policy is based not on assumptions
and inappropriate or invalid data, but on the best available data.
iii
t '
F
VI. ANALYSIS OF POSSIBLE REGULATORY APPROACHES
■ A legislated 100% smoke-free restaurant policy is the only effective way to
protect restaurant employees and patrons from the hazards of second-hand
smoke:
♦ A voluntary restaurant approach is ineffective because most restaurant
owners will not voluntarily prohibit smoking. Even if most do,many employees
will not be adequately protected. Restaurant workers cannot easily choose to
work only at smoke-free restaurants.
♦ Nonsmoking sections are not effective in protecting patrons or employees from
exposure to ETS. Peak concentrations of tobacco constituents are only modestly
decreased in remote locations and actually increased in locations closest to the
smoking area. Average concentrations are exactly the same, as are the adverse
health effects for employees.
■ Many city councils have required nonsmoking sections in an effort to protect
the public health. Unfortunately, the scientific evidence suggests that increasing
the size of nonsmoking sections will not increase protection for nonsmokers.
Enlarging nonsmoking sections will not significantly reduce restaurant patrons'
exposure to ETS, and will not reduce employees' ETS exposure at all.
• ■ Local governments that truly wish to protect restaurant employees and the
public from the hazards of restaurant ETS exposure have no effective
approach available, other than to legislate a 100% smoke-free policy.
VII. CITIES THAT HAVE ADOPTED 100% SMOKE-FREE RESTAURANT ORDINANCES
■ At least 24 U.S. cities have already adopted 100% smoke-free restaurant
ordinances.
VIII. ARGUMENTS AGAINST 100% SMOKE-FREE RESTAURANT ORDINANCES
■ The major arguments used by the tobacco industry and other groups against 100%
smoke-free ordinances are flawed. The benefits of protecting restaurant patrons
and employees from the health hazards of involuntary smoking by eliminating
exposure to ETS in restaurants far outweigh any possible costs.
iv
INTRODUCTION
"If AIDS was killing 350,000 Americans a year, efforts to
control the plague would be at crisis level.
If 350,000 Americans were dying every year in a pointless
war, angry protesters would be picketing the Pentagon and
barricading the Capitol.
If any other product were causing as much indoor air
pollution, environmental agencies would be insisting on
tighter regulations and expensive corrections...
Why aren't the same standards applied to cigarettes, which
are the single biggest source of preventable illness and
premature death today?" '
Smoking is the largest preventable cause of death in America today. It is related to
430,000 deaths each year: 112,000 from lung cancer, 31,000 from other cancers, 201,000
from cardiovascular disease, and 83,000 from chronic pulmonary disease.' Smoking is
not only a deadly addiction, but a costly one. Disease and lost productivity due to
smoking are costing the United States $65 billion a year? In California, smoking results
in more than 42,000 deaths and a total cost to the state of over $7.1 billion per year.`
Perhaps as disturbing as the effects of active smoking is the health impact of
involuntary smoking. The deaths of 53,000 people a years simply from breathing other
people's tobacco smoke is truly a tragedy.
Moved by the consequences of involuntary smoking, many local governments have
passed laws to protect nonsmokers from the health hazards of involuntary smoking in
public places, workplaces, and restaurants." Recently, two large cities (Sacramento and
Oakland) passed stringent ordinances which prohibit smoking in public places,
workplaces, and restaurants.
In considering restaurant smoking ordinances,policy-makers need to be well-informed
about a number of medical, scientific, economic, and legal issues in order to make
rational policy decisions. Presently, such information is not available in any organized
1
fashion. The purpose of this report is to provide the background information necessary
for legislators to formulate rational public policy in response to the public health
problem of involuntary smoking in restaurants. It attempts to compile, organize and
synthesize the key information and concepts that should guide the formulation of
restaurant smoking policy by legislators.
The report begins by reviewing the health effects and evaluating the public health
impact of involuntary smoking in general (Chapter 1). It then focuses on restaurants
specifically, evaluating the degree of exposure to environmental tobacco smoke (ETS) in
restaurants (Chapter 2) and the health effects of ETS exposure in restaurants (Chapter
3). Next, it examines the legal aspects of smoking in restaurants (Chapter 4). It proceeds
by evaluating the economic impact of 100% smoke-free restaurant ordinances (Chapter
5). Then, it presents and evaluates the approaches available to protect the nonsmoker
from restaurant ETS exposure (Chapter 6). It lists the cities that have adopted 100%
smoke-free restaurant ordinances (Chapter 7). Finally,it analyzes the major policy issues
which must be considered in the formulation of public policy to deal with the problem
of involuntary smoking in restaurants, focusing on arguments against smoke-free
ordinances (Chapter 8). Fact sheets that summarize the findings of each chapter are
included (Chapter 9). They may be reproduced and used to educate policy-makers so
that this report may become a part of the actual formulation of public policy on smoking
in restaurants.
2
I. HEALTH EFFECTS OF INVOLUNTARY SMOKING
The health effects of involuntary smoking have been reviewed extensively in the
epidemiologic literature, and by the Surgeon General', National Research Council' and
Environmental Protection Agency 3 In the most recent review,' environmental tobacco
smoke (ETS) was declared a class A carcinogen (a substance known to cause cancer in
humans for which there is no safe level of exposure). Table 1 summarizes the health
effects of involuntary smoking in children, pregnant women, healthy adults, and adults
with chronic heart or lung disease.
TABLE 1: Summary of Health Effects of Involuntary Smoking
GROUP EFFECTS
CHILDREN 1. Increased frequency of cough and wheezing.
2. Increased incidence of bronchitis, pneumonia and other
respiratory illnesses.
3. Increased rate of chronic ear infections.
4. Increased rate of middle ear effusions.
5. Small decreases in lung function (forced expiratory
volume) and reduction in lung growth which may be
factors in the development of chronic obstructive lung
disease later in life.
PREGNANT 1. Increased risk of low birth weight babies.
WOMEN
HEALTHY 1. Small decreases in lung function (forced expiratory flow
ADULTS rates).
2. Increased risk of heart disease (angina and myocardial
infarction) and death from heart disease.
3. Increased risk of lung cancer.
4. Increased risk of other cancers.
ADULTS WITH 1. Exacerbation of symptoms of chronic obstructive lung
CHRONIC LUNG disease.
OR HEART 2. Exacerbation of symptoms of asthma.
DISEASE 3. Exacerbation of symptoms of heart disease (angina).
4
II. INVOLUNTARY SMOKING-RELATED MORTALITY
There have been several attempts to estimate the annual number of deaths in the U.S.
attributable to involuntary smoking"'These risk assessments are remarkably consistent.
The best estimate of involuntary smoking-related mortality`,' is that 53,000 nonsmokers
die each year from exposure to other people's smoke: 37,000 from heart disease, 3,700
from lung cancer, and 12,000 from other cancers (Table 2).
TABLE 2: ANNUAL U.S. DEATHS FROM INVOLUNTARY SMOKING'
Heart Disease: 37,000
Lung Cancer: 3,700
Other Cancers: 12,000
TOTAL: 53,000
ANNUAL DEATHS FROM PASSIVE SMOKING
Heart Disease
37,000
a o0o Lung Cancer
Other Cancers
(22.6%)
53,000 Deaths Per Year
5
III. COMPARISON OF INVOLUNTARY SMOKING TO OTHER CAUSES OF DEATH
1. Comparison to Other Preventable Causes of Death:
Involuntary smoking is the third leading cause of preventable death, behind only
active smoking, and alcohol' (Table 3). It causes more deaths than motor vehicle
accidents10, AIDS", homicide" or drugs".
TABLE 3: TOP THREE CAUSES OF PREVENTABLE DEATH, U.S.
Cause Annual Deaths
Smoking 430,000,
Alcohol 98,000'
Involuntary Smoking 53,0004
PREVENTABLE CAUSES OF DEATH
30.00
100,000
d 300'000
}
a
r 200,000
CD
0
98 000
100,000
53,000 46 000
31 000 23 000
9 000
0
Smoking Aleohol PASSIVE Motor AIDS Homicides Drugs
SMOKING Aocldents
6
2. Comparison to Regulated Environmental Hazards
The cancer mortality alone from involuntary smoking is higher than the total cancer
mortality from all of the following environmental risks (regulated by EPA or other
government agencies) combined:
► All regulated outdoor air pollutants:
• radionuclides
• asbestos
• arsenic
• benzene
• coke oven emissions
• vinyl chloride
► Radiation
► Pesticides on food
► Active hazardous waste sites
► Inactive hazardous waste sites
► Chemicals in drinking water
► All workplace chemicals
► All consumer products (including asbestos)
► Pesticide application
► Contaminated sludge
► Mining wastes
Thus, involuntary smoking is the number one cause of environmental cancer,but is the
only exposure listed that is essentially unregulated (Table 4).
7
TABLE 4: INVOLUNTARY SMOKING VS. REGULATED ENVIRONMENTAL HAZARDS
HAZARD REGULATED DEATHS'
INVOLUNTARY SMOKING NO 15,700
Outdoor air pollutants Yes 87
Radionuclides 17
Asbestos 15
Arsenic <5
Benzene <8
Coke oven emissions <15
Vinyl chloride <27
Radiation Yes 406
Pesticides on food Yes 3000
Active hazardous waste sites Yes <50
Inactive hazardous waste sites Yes 500
Chemicals in drinking water Yes 591
All workplace chemicals Yes 127
All consumer products Yes 63
Pesticide application Yes 50
Contaminated sludge Yes 20
ng wastes Yes 10
TOTAL (excluding involuntary smoking) 4904
'Estimated annual cancer deaths. Data from reference 13,except outdoor air pollutant
risks, which are from reference 5.
8
CONCLUSION
1. Involuntary smoking causes:
♦ Increased frequency of cough and wheezing in children;
♦ Increased rates of pneumonia, bronchitis and other respiratory illnesses in
children;
♦ Reduced lung function and lung growth in children;
♦ Increased rates of chronic ear infections in children;
♦ Increased risk of heart disease in adults;
♦ Increased risk of lung cancer in adults;
♦ Increased risk of other cancers in adults;
♦ Exacerbation of symptoms in adults with chronic obstructive lung disease;
♦ Exacerbation of symptoms in persons with asthma; and,
♦ Exacerbation of symptoms in adults with heart disease.
2. Environmental tobacco smoke is a class A carcinogen - a substance known to cause
cancer in humans for which there is no safe level of exposure.
3. The best estimate of involuntary smoking-related mortality in the United States is
53,000 deaths per year: 37,000 from heart disease, 3,700 from lung cancer, and
12,000 from other cancers.
4. Involuntary smoking is the third leading cause of preventable death, behind only
active smoking and alcohol.
5. The cancer mortality from involuntary smoking alone exceeds the combined
mortality from all regulated environmental carcinogens.While involuntary smoking
is the number one cause of environmental cancer, it is essentially unregulated.
9
CHAPTER 2
ENVIRONMENTAL TOBACCO SMOKE EXPOSURE IN RESTAURANTS
It is clear that involuntary smoking is a major public health problem (Chapter 1). But
there are multiple sources of exposure to environmental tobacco smoke (ETS): domestic,
workplace, restaurant, etc. How important is restaurant ETS exposure compared to
domestic or typical workplace exposure? Are the actual health effects resulting from
restaurant exposure significant enough to justify legislative action to eliminate such
exposure?
This chapter will attempt to put the problem of involuntary smoking in restaurants
in proper perspective, by comparing restaurants to other sources of secondhand smoke.
There are two issues to consider:
(1) EXPOSURE - Does smoking in restaurants result in significant exposure to
tobacco smoke for restaurant employees? How does this exposure compare to
domestic and typical workplace exposure?
(2) EFFECTS - Does smoking in restaurants result in a significant increase in disease
or death for restaurant employees?
The exposure question will be evaluated in this chapter. The effects of restaurant
exposure will be reviewed in Chapter 3.
EXPOSURE TO ETS IN RESTAURANTS
Restaurant ETS exposure has been measured in a variety of ways, ranging from
ambient air sampling to biological measurements in exposed individuals.
A. MEASUREMENTS OF ETS CONSTITUENTS IN RESTAURANT AIR
The most extensive review of the literature was provided by Sterling et al.; who
summarize the results of numerous restaurant and workplace measurements. Their data
can be used to compare restaurant and typical workplace exposure to a number of ETS
constituents. The results are summarized in Table 5 and described below:
1. Carbon monoxide (CO): In the 36 offices studied, typical workplace concentrations
ranged from 1-3 parts per million (ppm). In the 76 restaurants studied, the mean CO
concentration was about 7 ppm,with a range of 2.6-9.9. Compared to typical workplaces,
then, restaurants appear to have about 31h times the concentration of CO.
10
2. Nicotine: The nicotine concentration in 44 offices studied was 0.9 Ng/m3. In the one
restaurant studied, the concentration was 5.2 (5 times higher).
3. Nitrogen Oxides: The concentrations of both NO2 and NO were about 3 times
higher in the two restaurants studied compared to 44 offices.
4. Nitrosamines: No restaurants have been studied, but the concentration of N-
nitrosodimethylamine was about 3 times higher in a bar than in a variety of smoke-
contaminated workplaces.
5. Particulates: The restaurants studied had particulate concentrations comparable to
those in 44 offices. These concentrations were about 3 times higher than in a home with
a smoker.
6. Aromatic hydrocarbons: Benzo(a)pyrene levels have been measured in several
restaurants, with concentrations ranging from 2.2 to 144 ng/m3. Unfortunately, there is
no typical workplace data to compare. However, two attempts have been made to
estimate restaurant employee exposure to benzo(a)pyrene in terms of active smoking
equivalents. Based on measurements in two smoke-filled taverns,Cuddeback'estimated
that benzo(a)pyrene exposure over an eight-hour work shift would be equivalent to that
obtained by smoking 12 and 36 cigarettes. Bridbord et al.' estimated that a nonsmoking
restaurant employee exposed to smoking and cooking fumes inhales the equivalent
benzo(a)pyrene intake of two packs of cigarettes per day. This was based on
measurements for the restaurant with the highest benzo(a)pyrene concentrations in Table
5.
Since the Sterling et al. review in 1982,' several other measurements of ETS in
restaurant air have been made. These measurements are comparable to the data in Table
3. Sterling et al.' reported mean CO concentrations of 3.9 ppm in the smoking area of a
cafeteria, and 2.6 in the nonsmoking area. Nicotine concentrations were 14 and 6.2
pg/m3. Vaughan and Hammond' reported mean nicotine concentrations of 2.4 to 11.6
pg/m3 in the nonsmoking areas of a cafeteria, and 10.2 to 13.2 in a snack bar.
Based on measurements of ETS constituents in restaurant air, exposure to ETS in a
typical restaurant is roughly 3-5 times higher than in a typical workplace. This is in
agreement with an estimate, based on the Environmental Protection Agency's
calculations of health risk, that the concentration of tobacco smoke in restaurants is 2-5
times that of a typical workplace.'Since typical workplace exposure dominates domestic
exposure (living with a smoker) by a factor of about 4 to 1,' restaurant exposure is about
8-20 times higher than domestic ETS exposure. Perhaps of even more concern, the most
heavily exposed restaurant employees inhale the benzo(a)pyrene equivalent of actively
smoking 11h to 2 packs of cigarettes per day.
11
TABLE 5: RESTAURANT VS. TYPICAL WORKPLACE EXPOSURE TO ETS'
RESTAURANT TYPICAL WORKPLACE
CONSTITUENT CONCENTRATION CONCENTRATION RATIO2
Carbon monoxide 4.0 (15 restaurants) 2.5 (10 offices) 3.5:1
(ppm) 5.1 0 restaurant) 1.0 0 office)
2.5 (1 restaurant) 2.8 (25 offices)
9.9 (14 restaurants)
8.2 (45 restaurants)
Nicotine 5.2 0 restaurant) 0.9 (44 offices) 5:1
(Ug/m3)
Nitrogen oxides 76 0 restaurant) 24 (44 offices) 3:1
NO2 (ppb) 63 0 restaurant)
Nitrogen oxides 120 0 restaurant) 32 (44 offices) 3:1
NO (ppb) 80 0 restaurant)
Nitrosamines 0.24 (bar) 0.05 (betting parlor) 3:1
(ng/L) 0.09 (disco)
0.09 (sports hall)
Particulates .110 (1 restaurant) .13 (44 offices) 1:1
(mg/m3) .109 (1 restaurant) .035 (home with 1
.086 0 restaurant) smoker)
.107 0 restaurant)
Benzo(a)pyrene 6.2 0 restaurant)
(ng/m3) 28.2-144 0 restaurant)
13.3 (reference 2)
2.2 (reference 2)
'Data from reference 1
'Ratio of restaurant to workplace concentration
12
B. GENOTOXICITY OF ETS SAMPLES FROM RESTAURANTS
Two studies have evaluated restaurant ETS exposure by testing restaurant air samples
for their ability to induce mutations and chromosomal aberrations in bacteria and cell
cultures:
a. Husgafvel-Pursiainen et al.' found that air samples from the three restaurants
studied caused significant increases in both mutation and chromosomal
aberration rates. The genotoxicity of restaurant air was found to exceed by 1_2
orders of magnitude that of previously measured urban outdoor and indoor air
samples.
b. Teschke et al." compared the mutagenicity of restaurant air to that of previously
studied workplace air. In restaurant dining areas, potencies of 422 and 828
revertants/m3 were found. This compares to frequencies of up to 79 in
polyurethane manufacturing plants and up to 101 in foundry samples.
C. BIOLOGICAL MEASUREMENTS IN EXPOSED RESTAURANT WORKERS
Two studies have evaluated restaurant ETS exposure by measuring tobacco smoke
parameters in body fluid samples of restaurant employees:
a. Husgafvel-Pursiainen et al.10 found elevated levels of plasma and urine cotinine as
well as plasma thiocyanate (indicators of exposure to ETS) in nonsmoking
waiters and waitresses. There was also an increase in the urine mutagenicity of
these employees,which was intermediate between that of non-exposed and actively
smoking workers.
b. Maclure et al." found elevated levels of 3-aminobiphenyl, a carcinogenic
hemoglobin adduct, in smoke-exposed bartenders. Their levels of this carcinogen
were about 2-3 times higher than in subjects with typical environmental tobacco
smoke exposure.
i
'Genotoxicity is the ability of a chemical to cause changes in the structure of DNA
or chromosomes. Mutagenicity is the ability of a chemical to cause changes in the coding
sequence of DNA.
P
13 f
CONCLUSION
1. Restaurant employees' ETS exposure is about 3-5 times higher than that of
employees in a typical workplace.
2. Restaurant employees' ETS exposure is about 8-20 times higher than individual
domestic exposure.
3. The most heavily exposed restaurant workers inhale the benzo(a)pyrene
equivalent of actively smoking 11/i to 2 packs of cigarettes per day.
4. The genotoxicity of restaurant air is 10-100 times that of previously measured
urban outdoor and indoor air.
5. The mutagenic potency of restaurant air is 5-10 times that of "high-risk" industrial
workplace air.
6. Heavily exposed restaurant workers have levels of carcinogens in their blood 2-3
times higher than persons with typical ETS exposure, and have higher levels of
mutagenicity in their urine.
7. Restaurant employees are therefore the occupational group most heavily exposed
to ETS and most likely to suffer adverse health effects due to ETS exposure.
14
CHAPTER 3
HEALTH EFFECTS OF ETS EXPOSURE IN RESTAURANTS
Restaurant employee exposure to environmental tobacco smoke (ETS) appears to be
3-5 times higher than typical workplace exposure and 8-20 times higher than domestic
exposure (chapter 2). Given the significantly increased risk of heart disease and lung
cancer attributable to domestic ETS exposure (chapter 1), one would expect to find
increased rates of involuntary smoking-related disease and death in restaurant
employees. Is this the case? Is involuntary smoking in restaurants actually causing a
significant amount of disease and death in restaurant workers?
To evaluate this question, the epidemiologic literature was reviewed. Many studies
have found a significantly elevated risk of lung cancer in food service workers. The
results are summarized in Table 6, and described below:
a. Doebbert et al.' studied the occupational mortality of California women from 1979
to 1981. Among white women, waitresses had the highest mortality rates, with an
overall 147% excess risk of death. Heart disease mortality was 156% higher than
expected, and lung cancer mortality was 268% higher.
b. Andersen et al.' found a 53% excess lung cancer risk in waiters in Norway.
c. Menck and Henderson' reported a 71% excess lung cancer risk in white males
working in the food and drink industry.
d. Dimich-Ward et al.' studied bartenders and waiters in British Columbia. They
found an excess lung cancer risk of 33% for males and 65% for females.
e. Lynge' found an excess lung cancer risk of 132% in Danish waiters.
f. Williams et al.' studied occupational mortality using data from the Third National
Cancer Survey. For women, excess lung cancer risk was 67% for the food and drink
retail industry, and 88% for food service workers. The results were controlled for
age, race, education, tobacco, and alcohol use.
g. Zahm et al.' conducted a case-control study using the Missouri Cancer Registry.
The excess risk of lung cancer among male food service personnel was 80%,
controlled for active smoking.
15
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TABLE 6: STUDIES OF LUNG CANCER RISK IN FOOD SERVICE WORKERS
STUDY EXCESS LUNG
(ref. no.) SUBTECTS CONTROLLED?' CANCER RISK
FEMALES
1 California No 268%
waitresses
4 British Columbia No 65%
bartenders/waiters
6 U.S. food service Yes 88%
workers
MALES
2 Norwegian waiters No 53%
3 Los Angeles food and No 71%
drink industry
workers
4 British Columbia No 33%
bartenders/waiters
5 Danish waiters No 132%
7 Missouri food Yes 80%
service workers
'Are results controlled for active smoking?
16
There are several possible confounding variables that could explain an elevated lung
cancer risk in food service workers.These include active smoking, socio-economic status,
stress, and social support.' Of these, active smoking is the most important. There are
four reasons to believe that smoking does not fully explain the increased risk of lung
cancer in food service workers:
1. Smoking rates among U.S. waiters are comparable to those for the general
population. The 1970 Health Interview Survey' found a current smoking rate of 45% in
waiters versus 43% in the male population. Thus, confounding by active smoking is
unlikely to explain the increased risk estimates for waiters, at least in the U.S. studies.
The smoking rate for waitresses (50%) was significantly higher than for the female
population (31%), so active smoking is an important confounder for the results in
women.
2. Levin et al.' designed a study specifically to determine the excess occupational
lung cancer risk in U.S. waitresses that could be explained by active smoking. They
found that failure to control for active smoking could result in the detection of a 50%
excess lung cancer risk. Thus, although smoking is an important confounder, it is
unlikely to explain all of the excess risk of lung cancer in U.S. waitresses.
3. Using data from the National Health Interview survey, the risk estimates in the
California Occupational Mortality study were adjusted for smoking, alcohol, and socio-
economic status.10 While the excess lung cancer risk for waitresses decreased
considerably after adjustment, it remained significant at 48%.
4. The two studies that did control for active smoking found an 80-90% excess risk
of lung cancer in both waiters and waitresses.6,7 This is consistent with the finding of
a 71% excess lung cancer risk in Los Angeles waiters, which should not be confounded
by smoking for the reason outlined above. The Williams study' also controlled for
education, so much of the potential significant confounding was probably removed.
Although additional studies are needed to more accurately quantify the excess lung
cancer risk, the preliminary evidence suggests that waiters and waitresses have about
a 50-90% excess lung cancer risk, controlling for significant confounding variables.
While part of this excess risk could be due to cooking fumes, it is likely that most of the
excess risk is attributable to ETS exposure.
It appears, then, that waiters and waitresses have 11h to 2 times the risk of dying from
lung cancer compared to the general population, due in part to restaurant ETS exposure.
This is quite plausible, given the extremely high exposure to ETS in restaurants and the
known health risks of ETS at considerably lower levels of exposure.
F
§� 17
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CONCLUSION
I. In California, waitresses have the highest mortality of any female occupational
group. They have almost 4 times the expected lung cancer mortality and 21A times
the expected heart disease mortality rate.
2. The preliminary evidence suggests that waiters and waitresses have about a 50-90%
increased risk of lung cancer that is most likely attributable to restaurant
tobacco smoke exposure. Thus, exposure to ETS at work makes restaurant workers
Ph to 2 times as likely to die from lung cancer as they would otherwise be.
3. Although not yet studied, the morbidity and mortality of restaurant workers from
heart disease attributable to restaurant ETS exposure is expected to be even more
significant than for lung cancer. (Heart disease causes ten times the number
of deaths from lung cancer in involuntary smokers.)
18
CHAPTER 4
SMOKING IN RESTAURANTS: THE LEGAL SITUATION
Given the magnitude of environmental tobacco smoke's health effects (Chapter 1),and
the fact that restaurant employees have the highest workplace exposure (Chapter 2), is
there a legal argument for regulating smoking in restaurants? Does the restaurant
employee have a right to a smoke-free work environment?
This chapter will examine two questions:
(1) Are restaurant employers obligated to protect their employees from the health
hazards of ETS?
(2) Are restaurant employers liable for damages to workers if they fail to protect them
from ETS?
I. Are restaurant employers obligated to protect their employees from the health hazards
of ETS?
A. COMMON LAW DUTY TO PROVIDE A SMOKE-FREE WORK ENVIRONMENT
Under the common law', employers are required to provide a work environment
reasonably free of recognized hazards. The employer must use reasonable care in
providing his employees with a safe working environment, protecting them from
avoidable hazards. Based on evidence of the health effects of involuntary smoking,
courts have ruled that this common law duty requires employers to provide nonsmoking
employees with an environment free from tobacco smoke. Through several court
opinions, the definition of tobacco smoke as an avoidable occupational hazard, and the
right of the nonsmoking worker to be protected from this hazard, have been accepted:
Shimp v. New Jersey Bell Company:' A secretary working for the telephone company
who was allergic to cigarette smoke sought an injunction requiring a smoking ban. The
court ordered the employer to provide a safe working environment for the plaintiff by
restricting smoking to a non-work area. The decision was based on four major principles:
'Common law is the body of law that is based on court decisions rather than on
government legislation and regulations.
19
1. "It is clearly the law in this State that an employee has a right to work in a safe
environment. An employer is under an affirmative duty to provide a work area that
is free from unsafe conditions."
2. '"There is no necessity to fill the air with tobacco smoke in order to carry on
defendant's business, so it cannot be regarded as an occupational hazard which
plaintiff has voluntarily assumed in pursuing her career as a secretary."
3. "When an employer is under a common law duty to act, a court of equity may
enforce an employee's rights by ordering the employer to eliminate any
preventable hazardous condition which the court finds to exist."
4. "There can be no doubt that the by-products of burning tobacco are toxic and
dangerous to the health of smokers and nonsmokers generally and this plaintiff in
particular."
Smith v. Western Electric Company:'The employee sought an injunction requiring the
employer to provide him with smoke-free working conditions. The Missouri Court of
Appeals overturned a trial court's dismissal of the plaintiff's action. The court concluded
that "by failing to exercise its control and assume its responsibility to eliminate the
hazardous conditions caused by tobacco smoke,defendant has breached and is breaching
its duty to provide a reasonably safe workplace."The decision was based on three major
principles:
1. "It is well-settled in Missouri that an employer owes a duty to the employee to use
all reasonable care to provide a reasonably safe workplace, and to protect the
employee from avoidable perils."
2. "The allegations of the instant case, taken as true, show that the tobacco smoke
of co-worker smoking in the work area is hazardous to the health of employees in
general and plaintiff in particular."
3. "The allegations also show that defendant knows the tobacco smoke is harmful to
plaintiff's health and that defendant has the authority, ability, and reasonable
means to control smoking in areas requiring a smoke-free environment."
Lee v. Department of Public Welfare:3 A social worker sued her employer, seeking an
injunction to relieve her from exposure to tobacco smoke at work. An attempt by the
employer to dismiss the case was denied by the Massachusetts Superior Court: "An
employer has no duty to make the workplace safe if, and only if, the risks at issue are
inherent in the work to be done. Otherwise, the employer is required to take steps to
prevent injury that are reasonable and appropriate under the
circumstances...Accordingly, this court cannot say that the plaintiff's claim fails to make
out a legally cognizable basis for relief."
20
It is clear that based on tort common law, the nonsmoker does have a right to a work
environment free from tobacco smoke. Does this right extend to restaurant employees?
In the language of the precedent cases, the key issue is whether or not smoking in
restaurants is: (1) "necessary to carry out business", (2) an "avoidable peril", or (3)
"inherent in the work to be done". It is unlikely that any court would find that long-term
exposure to a class A carcinogen is inherent in being a waiter, or is unavoidable.
Thus,under the common law,restaurant employers are required to provide employees
with a smoke-free work environment. Since segregation of smokers and nonsmokers
does not reduce ETS exposure (see Chapter 6), reasonable accommodation of employees
may require a 100% smoke-free policy, unless a separately ventilated room is available
for smoking, in which the employee is not asked to work.
B. FEDERAL AND STATE LAWS TO PROTECT HANDICAPPED EMPLOYEES
The common law provides protection from ETS for nonsmoking employees in general.
Additionally, Federal and California state law provide protection for employees who are
particularly sensitive to smoke.
First, the National Rehabilitation Act of 1973 holds that employers must make
of accommodation" for employees who are handicapped. Two recent federal
decisions have classified employees who are extremely sensitive to tobacco smoke as
handicapped. In Pletten v. U.S. Army' the U.S. Merit Systems Protection Board ruled
that Leroy Pletten was handicapped because he suffered from asthma, and was
especially sensitive to tobacco smoke. The employer was required to make a reasonable
accommodation, which in this case was a prohibition of smoking in Pletten's Division.
In Vickers v. Veterans Administration s a U.S. District Court ruled that the plaintiff was
handicapped because he "is unusually sensitive to tobacco smoke and that this
hypersensitivity does in fact limit at least one of his major life activities, that is, his
capacity to work in an environment which is not completely smoke-free."
Second, the California Fair Housing and Employment Act requires reasonable
accommodation for employees who are handicapped. In County of Fresno v. Fair
Employment and Housing Commission,' a California Court of Appeals ruled that two
employees who were sensitive to tobacco smoke due to underlying lung disease were
handicapped under the Act, and thus entitled to reasonable measures to protect them
from tobacco smoke exposure. In this case, banning smoking in the employees' work
area would have been required to satisfy the provisions of the Act.
' 21
Thus, under Federal and state law, restaurant employers are required to take
reasonable measures to provide a smoke-free work environment for employees who are
especially sensitive to tobacco smoke. Again, this would probably require a 100% smoke-
free policy, unless a separately ventilated smoking room were available, in which the
employee was not asked to work.
II. Are restaurant employers liable for damages to their workers if they fail to protect
them from ETS?
There are three areas of liability for employers who fail to protect their employees
from the hazards of ETS: workers' compensation and disability, personal injury due to
employee negligence under common law, and unemployment compensation. Since the
duty to provide a smoke-free work environment applies to restaurant employers, the
three areas of liability apply as well.
A. WORKERS' COMPENSATION AND DISABILITY
The most compelling example of potential liability under workers' compensation is the
1990 California case of Ubhi V. State Compensation Insurance Fund. Ubhi, a
nonsmoking waiter who suffered a heart attack he claimed was due to restaurant
tobacco smoke exposure, received a settlement of$85,000 from the state Compensation
Insurance Fund.
There are numerous cases in which workers' compensation and disability awards for
injury caused by exposure to workplace ETS have been upheld at the claims appeal or
judicial level, or in which the claims were uncontested:
1. Kufahl v` Wisconsin Bell Inc.-' Wisconsin Bell paid Deborah Kufahl $23,400 in
workers' compensation for permanent disability due to eight years of exposure to
secondhand smoke. Kufahl suffered headaches, nausea, fatigue and dizziness
when.exposed to ETS.
2. Brooks v. TWA and Liberty Mutual Insurance:' An airline stewardess received
workers' compensation from TWA and Liberty Mutual for injury due to an allergic
reaction to tobacco smoke.
3. Bena v. Massachusetts Turnpike Authorit :10 An administrative judge awarded
compensation to an ex-smoker for exacerbation of his chronic obstructive lung
disease by workplace ETS exposure.
22
e
4. lohannesen v. New York City Dept. of Housing Preservation and Development:"
Compensation was awarded to an employee who developed asthma from repeated
workplace ETS exposure.
5. Schober v. Mountain Bell Telephone:" A New Mexico Court of Appeals awarded
partial permanent disability benefits for injury due to an allergic reaction to
tobacco smoke at work.
6. Teri Way of Wisconsin was granted total permanent disability due to exposure to
smoke in the workplace.13
7. Economist Werner Peterke received workers' compensation for asthma and
bronchitis induced by smoking in his place of work.13
8. Linda Batchelor of California won a workers' compensation award of $17,500 for
headaches and other acute symptoms she suffered while surrounded by workplace
smoke.14
B. EMPLOYER NEGLIGENCE UNDER COMMON LAW
Since the employer has a common law duty to protect the employee from ETS, can the
employee collect damages for workplace ETS-induced injury? In most cases, the
exclusive remedy provision of state workers' compensation law will preclude such a
lawsuit. However, if a smoke-related injury is deemed not to be covered within the
scope of workers' compensation, the employee has a legitimate common law negligence
action against the employer for failure to provide a smoke-free workplace.
In McCarthy v. State of Washington 15 the Washington Supreme Court ruled that an
employee who developed disabling chronic obstructive lung disease from years of
workplace ETS exposure could sue the employer for failure to protect her from the
hazards of ETS. The suit was not pre-empted by state workers' compensation law
because the disease was felt to lie outside its coverage. This is a landmark decision
because it essentially ensures that employees who do not receive workers' compensation
for workplace ETS-induced injury can file negligence suits against the employer for
failing to comply with the common law duty to protect the employee from such
exposure. In the McCarthy case, the suit was settled out of court for $27,000.
23
C. UNEMPLOYMENT COMPENSATION
There is now a strong legal precedent in California for employees to collect
unemployment compensation benefits if they terminate employment because of fear of
health damage from ETS. The California Court of Appeals has twice awarded a plaintiff
unemployment compensation benefits after the voluntary termination of employment
simply for fear of health damage from involuntary tobacco smoke exposure.16,"
1. In Alexander v. Unemployment Insurance Appeals Board,16 the Board was forced
to pay unemployment insurance benefits to an X-ray technologist who quit her job
because of an allergy to tobacco smoke.
2. In McCrocklin v. Employment Development Department," the Court awarded
compensation to an engineering writer who left his job for fear that he was being
exposed to carcinogens in ETS. The employee was not allergic to tobacco smoke,
and had in fact smoked a pipe and cigars in the past.
Similar rulings have been made in New Jersey, Pennsylvania, and Georgia:
3. In Appell v. Morristown Board of Education,18 an employee was awarded
compensation after resigning due to eye irritation and headaches due to smoke
exposure.
4. In Lal2ham v. Commonwealth of Pa.UnemployMent Compensation Board of
Review,19 an employee was awarded benefits after resigning due to allergic
bronchitis caused by workplace smoking.
5. In Georgia, a State Merit System employee won three months of benefits after
leaving her job because of cigarette smoke.13
I _
i.
24
i
CONCLUSION
It is clear that restaurant employers are required, under common law, to provide a
smoke-free work environment for employees. In addition, under Federal and state law,
they must protect employees who are especially sensitive to smoke by providing a
smoke-free work environment. When they fail to do so, employees have three potential
remedies:
1. To collect workers' compensation benefits for ETS-induced injury;
2. To file suit against the employer for damages due to failure to protect from the
hazards of ETS, if the injury is ruled not to be within the scope of workers'
compensation; and,
3. To terminate employment for fear of health damage from ETS, and collect
unemployment compensation benefits.
Claims in each of these three areas have been made by employees affected by ETS at
work, upheld by the courts, and have resulted in numerous large awards or settlements.
The protection for nonsmoking workers in California is particularly strong.
With increasing public awareness of the health hazards of secondhand smoke, the
significance of employer liability for ETS-induced injury will increase. In fact, several
recent legal reviews document the increase in involuntary smoking claims against
employers."'3 As one review points out, employers are no longer immune from liability
for ETS-related injury: 'Today, the situation is different. Actions against employers are
common...".20 Recently, one lawsuit against an employer was filed for $5 million.11
Regardless of the outcome of these suits, employer liability for ETS-induced worker
injury will become an increasingly important issue for employers. Potential liability can
be eliminated, however, by acting to protect nonsmoking employees from the hazards
of ETS.
25
CHAPTER 5
ECONOMIC IMPACT OF 100% SMOKE-FREE RESTAURANT ORDINANCES
Perhaps the issue most important to policy-makers is the economic impact of smoke-
free restaurant ordinances. Do these laws have a significant effect on restaurant
business? Proponents and opponents of these measures have provided a wide range of
evidence,from anecdotal reports to rigorous scientific studies, to support their positions.
This chapter will evaluate the evidence in three steps:
1. It will analyze the potential approaches to studying the question and point out
significant problems with each approach.
2. It will suggest a set of criteria that evidence must meet in order to provide an
accurate evaluation of economic impact.
3. It will review the evidence that meets these criteria in an attempt to answer the
question based on the best available evidence.
I. ANALYSIS OF APPROACHES TO EVALUATING THE ECONOMIC IMPACT OF
SMOKE-FREE RESTAURANT ORDINANCES
1. Anecdotal reports: Tobacco industry lobbyists often provide anecdotal reports of
restaurants that go out of business or suffer economic losses after implementation of
smoke-free ordinances.',' While effective at stimulating emotion, such reports do little to
provide information on the impact of an ordinance. First, whether or not an ordinance
is implemented, there will be restaurants that go out of business. Anecdotal evidence
cannot demonstrate that the ordinance was the cause of the restaurant's problems.
Similarly, anecdotal reports of restaurants with increased sales after implementation of
an ordinance do not necessarily demonstrate a positive effect of the ordinance. Second,
anecdotal reports are severely biased in that only restaurants with economic losses are
sampled. They give no information whatsoever about the overall impact of an ordinance
on business in a community.
2. Newspaper reports: Tobacco industry lobbyists often use newspaper articles as
evidence for an adverse economic impact of smoke-free ordinances.1,2 Newspaper reports
of the effect of ordinances are subject to the same biases as anecdotal reports, and for the
reasons outlined above, are of no value in evaluating the economic impact of smoke-free
restaurant ordinances.
26
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j
3. Letters from restaurant owners: Tobacco industry lobbyists often provide letters
from restaurant owners who claim a loss of business due to an ordinance.' This type
of evidence is equivalent to anecdotal reports. There will be restaurants with increases
and decreases in business, regardless of the passage of a smoking ordinance. In addition,
restaurant owners who oppose the ordinance tend to attribute their losses to the
ordinance. The sample is also biased because only owners who perceive a negative
impact are sampled. Again, this type of evidence provides little useful information on
the economic impact of an ordinance.
4. Repeal of an ordinance: The fact that the Beverly Hills City Council repealed its
ordinance has been used as evidence of the adverse economic impact of the ordinance.
As will be shown, there was no significant change in restaurant sales in Beverly Hills
after implementation of the smoke-free ordinance. In fact, the Council's decision to
repeal the ordinance is evidence of the danger of using anecdotal data to guide public
policy. The tobacco industry used such poor data to convince legislators of an economic
impact that did not exist.
5. Restaurant surveys: Although a slight improvement over anecdotal reports,
restaurant surveys are an inadequate method of evaluating the economic impact of an
ordinance. While useful in measuring the perceptions of restaurant owners prior to
consideration of an ordinance, a more reliable measure of economic impact is necessary
to measure the overall effect after implementation of an ordinance. There are two major
problems with restaurant surveys. First, they are subject to severe sampling bias. A
perfect example of this is the survey of Bellflower restaurants, performed at the direction
of Mayor Bill Pendleton.' The survey used a non-random, non-probability sampling
scheme, making it completely invalid. In addition, the response rate was only 33% and
no attempt at follow-up for non-response was made. Restaurants with perceived losses
in business were more likely to respond, biasing the results further. The survey
concluded that there had been a 30% loss in business, when in fact (as will be shown
later) there was no significant effect on restaurant business. Second, surveys are subject
to measurement bias, because restaurant owners' attitudes towards an ordinance will
affect their perception of its effects. To a large extent, the results of a restaurant survey
could be predicted before the survey is conducted, based on the attitudes of the owners
of those restaurants surveyed.
6. Analysis of sales tax data for specific quarters: The use of sales tax data to evaluate
the economic impact of smoke-free ordinances is a vast improvement over the above
methods. The information is objective, and not subject to measurement bias. All
restaurants are sampled, so there is no sampling bias. However, the comparison of two
specific data points is invalid. By careful selection of the appropriate quarters, one can
show almost any kind of effect that one desires. This is illustrated by tobacco industry-
sponsored research on the effects of the Beverly Hills ordinance:
27
Laventhol and Horwath4 evaluated the effect of the Beverly Hills ordinance by
comparing restaurant sales in the 2nd quarter of 1987 (just after implementation) to sales
in the 2nd quarter of 1986. They reported a 6.7% decrease ($24.3 million vs. $26.0
million). However, they could just as easily have compared the 2nd quarter of 1987 to
the 3rd or 4th quarters of 1986 or 1st quarter of 1987, in which case they would have
found increases of 5.3%, 6.2%, and 12.1%, respectively. Or, one could compare the 3rd
quarters of 1987 and 1986, in which case one would find a 6.4% increase in sales. The
data is shown below in Table 7.
TABLE 7: Demonstration of the Invalidity of Comparing Sales Tax Data for Specific
uarters
RESTAURANT SALES (millions of dollars),
Beverly Hills, CA
Quarter (before ordinance) Quarter (after ordinance) Change
2nd, 1986: 26.019 2nd, 1987: 24.275 -6.7%
3rd, 1986: 23.061 2nd, 1987: 24.275 +5.3%
4th, 1986: 22.856 2nd, 1987: 24.275 +6.2%
1st, 1987: 21.651 2nd, 1987: 24.275 +12.1%
3rd, 1986: 23.061 3rd, 1987: 24.536 . +6.4%
7. Analysis of sales tax data in an econometric model: Glantz and Smiths developed
a model which uses linear regression to analyze sales tax data, while controlling for
potential confounding variables. Bias in selecting specific quarters is eliminated,because
data for all quarters after an ordinance is implemented, and for several years before
implementation, is put into the model. This controls for trend and fluctuation in the
data. Trend in economic conditions is controlled by incorporating total retail sales data
as well as data for comparison cities.
Unlike all of the above approaches, this type of approach is a valid, objective,
unbiased and accurate way of evaluating the economic impact of smoke-free restaurant
ordinances. It is the best available method to evaluate the economic impact of smoke-free
ordinances.
28
II. CRITERIA TO EVALUATE THE VALIDITY OF STUDIES OF THE ECONOMIC
R%4PACT OF SMOKE-FREE ORDINANCES
Based on the above analysis, the following criteria are suggested as a guide to policy-
makers to evaluate the validity of studies of the economic impact of smoke-free
restaurant ordinances:
1. The study should be based on objective data, such as sales tax data provided by the
Board of Equalization.
2. All data points after the ordinance was implemented, and for several years before,
should be included in the analysis.
3. The data should be analyzed using a regression or similar statistical model, so that
the significance of any change can be evaluated in light of the trend and fluctuation
in the data.
4. Overall economic trend should be controlled for by the use of total sales data and
data from comparison areas.
M. REVIEW OF STUDIES THAT MEET VALIDITY CRITERIA
There has been only one study, to date, that meets the above criteria. Glantz and
Smith' used an econometric model to analyze sales tax data for the cities of Lodi,
Bellflower, Beverly Hills, and San Luis Obispo, before and after the adoption of a 100%
smoke-free ordinance. They found no significant effect of the ordinance on total
restaurant sales, restaurant sales as a fraction of total retail sales, or restaurant sales in
comparison to a control community without the ordinance, for each of the 4 cities
studied. In Beverly Hills, they also found no significant increase in sales after repeal of
the ordinance. They conclude that "there is no evidence that 100% smoke-free restaurant
ordinances have any effect on restaurant sales, either in absolute terms or in comparison
with similar cities that have no such health and safety requirements."
The study shows that the Tobacco Institute claim of a 30% decrease in restaurant sales
in Beverly Hills' was wrong, and demonstrates the invalidity of the survey which found
a 30% decrease in business in Bellflowe? and of the Laventhol and Horwath study,`
which found a 7% decrease in sales in Beverly Hills.
29
r
This chapter has shown that based on the best available evidence, 100% smoke-free
restaurant ordinances do not have a significant impact on restaurant sales. It has also
demonstrated how easily policy-makers can be misled if they fail to evaluate the validity
of the evidence that is presented to them, and has suggested a set of criteria to evaluate
evidence in the future. This will help ensure that public policy is based on the best and
most accurate data available.
I
CONCLUSION
1. Based on the best available evidence, 100% smoke-free ordinances have no
significant impact on restaurant sales.
2. Studies that found a decrease in restaurant sales in Beverly Hills and Bellflower had
serious methodologic flaws, and are invalid.
3. The use of anecdotal evidence and restaurant surveys is inherently biased and
inappropriate in analyzing the economic impact of smoke-free ordinances; it does
not provide information useful in evaluating this issue.
4. Public policy-makers have been misled about the economic impact of restaurant
smoking ordinances, by studies based on invalid evaluation approaches, such as
those mentioned above. Before being considered seriously, evidence should be
evaluated on criteria which include the use of actual sales tax data, inclusion of all
data points before and after implementation of an ordinance, the use of regression
or other statistical methods to control for trend and fluctuation in the data, and
appropriate control for overall economic trend. This will help ensure that public
policy is based not on assumptions and inappropriate or invalid data, but on the
best available data.
30
CHAPTER 6
ANALYSIS OF POSSIBLE REGULATORY APPROACHES
There are several possible approaches to protecting the nonsmoker from
environmental tobacco smoke (ETS)in restaurants.These range from relying on common
courtesy all the way to banning smoking completely. This chapter will analyze the
effectiveness of each of these potential approaches.
I. COMMON COURTESY
The tobacco industry argues that the best way to resolve the conflict between the
smoker and nonsmoker is by an approach based on "common courtesy".' Smokers
should ask those around them if they mind before lighting up, and nonsmokers should
"mention annoyances in a pleasant and friendly manner...". This approach was reviewed
in a report on involuntary smoking by the Conservation Law Foundation of New
England.' The report outlines two reasons why relying on common courtesy is
ineffective. First, "relying on the exercise of common sense and common courtesy to
solve the problem of indoor air pollution ignores the habitual character of smoking and
places upon the individual nonsmoker the burden of imposing restraint upon the
smokers sharing his or her air. This burden is at best an awkward one and at worst
results in a public policy of silent acquiescence." Second, the tobacco industry has itself
opposed self-restraint, by waging a campaign to encourage existing smokers to smoke
more as well as to recruit new smokers: "Restraint is as unlikely to become a part of the
smoker's approach to smoking as it is to characterize the industry's marketing strategy
unless and until it is imposed by some other authority."
A recent study published in the Journal of the American Medical Association
examined the effectiveness of the common courtesy approach? It found that 47% of
smokers do not ask others if they mind before lighting up, and that only 4% of
nonsmokers will actually ask smokers not to smoke, despite annoyance and knowledge
of the harmful effects of ETS. The authors conclude that "the common courtesy approach
endorsed by the tobacco industry is unlikely, by itself, to eliminate exposure to ETS,"
and that "legislative or administrative mechanisms are probably the only effective
strategies to eliminate exposure to ETS."
2. VOLUNTARY RESTAURANT SMOKE-FREE POLICIES
A second approach is to encourage voluntary restaurant smoke-free policies,and allow
customers to choose whether or not they wish to dine in such restaurants. There are
three reasons why this strategy is ineffective:
31
a. Most restaurant owners do not and will not voluntarily prohibit smoking: This
question was actually examined in a study by researchers at DePaul University." They
conducted an intensive educational campaign to encourage Chicago restaurateurs to
simply establish nonsmoking sections. Free publicity was offered, as was channeling of
customers who had expressed a preference for restaurants with nonsmoking sections.
Nevertheless, only 10% of the restaurants established permanent nonsmoking sections.
The authors conclude that: "the restaurateurs' disinclination to voluntarily establish
nonsmoking sections seems to indicate the necessity for legislative efforts to mandate
nonsmoking sections."
b. Even if restaurants become smoke-free, nonsmokers will not be adequately
protected: As about 75% of the population does not smoke, nonsmokers will not be
adequately protected from ETS unless about 75% of restaurants are smoke-free.
c. Even if many restaurants become smoke-free restaurant employees will not be
adequately protected: Restaurant employees cannot simply choose to work only in
smoke-free restaurants. Thus, a voluntary approach is in no way effective in protecting
restaurant employees from ETS.
3. SEPARATE SMOKING AND NONSMOKING SECTIONS
There is little doubt that segregation of smokers and nonsmokers is not effective in
protecting the nonsmoker from ETS. This is because smoke is carried to all areas of an
enclosed room. In fact, after one hour of air mixing, there is little difference between
smoking and nonsmoking sections.'Several studies have documented the ineffectiveness
of this approach:
a. Olshansky' studied tobacco smoke exposure of smokers and nonsmokers in a large
hall with central air conditioning and six electrostatic air cleaners. He found that
carbon monoxide (CO), carboxyhemoglobin, and ambient CO levels were nearly
identical in the smoking and nonsmoking sections, and concludes that the CO
"simply diffused uniformly throughout the entire hall."
b. Sterling and Mueller' measured air concentrations of CO, nicotine, and respirable
suspended particles (RSP) in nonsmoking areas of a cafeteria. Compared to a
nonsmoking office area, the concentration of CO was twice as high, the nicotine
concentration was six times higher, and the RSP concentration was five times
higher. The reduction in the level of contamination compared to the smoking area
was only 50%.
c. Repace and Lowrey' found that physical separation of nonsmokers and smokers
within a given space reduces only peak concentrations of tobacco smoke, not
average concentrations. Therefore, it does not reduce the risk of adverse health
effects when a person is subjected to long-term exposure.
32
One study actually found an increase in tobacco smoke exposure in certain areas of
a cafeteria after a smoking area was designated. Vaughan and Hammond9 found a 200-
500% increase in nicotine concentration in the nonsmoking location nearest the newly
designated smoking area. The remote locations of the nonsmoking area showed only a
50% reduction. The overall cafeteria readings were 16% hi her after designation of the
smoking area.
Finally, not only is segregation completely ineffective in protecting nonsmoking
patrons, it in no way serves to protect restaurant employees. As Repace and Lowrey
point out,' even if a waiter works only in the nonsmoking section, the average exposure
to ETS will be no different than without segregation, and the risk of adverse health
effects will not be reduced.
4. SEGREGATION AND VENTILATION/FILTRATION
Most studies agree that filtration and ventilation of tobacco smoke are both ineffective
methods of protecting the nonsmoker:
a. In a study in a hotel meeting room,10 modern ventilation and filtration equipment
did not adequately reduce CO levels. The ambient CO concentrations were 8-10
parts per million (ppm), and 7 ppm in the alveoli of nonsmokers. Smoking
cessation was required to bring the CO concentration to the desired level (1-2 ppm,
2-3 ppm in alveoli of nonsmokers).
b. The American Society of Heating, Refrigerating, and Air Conditioning (ASHRAE)
sets minimum design ventilation rates for buildings. Repace" estimated that at the
ventilation rates prescribed for buildings with smoking (25 fe/min/occupant),
nonsmokers would still inhale the equivalent of 21h cigarettes per workday.
c. Repace and Lowrey" showed that within the practical range of achievable
ventilation rates, the "respirable suspended particle levels generated by smokers
overwhelm the effects of ventilation and inflict significant air pollution burdens on
the occupants." They also showed that high-volume electrostatic filters are
ineffective under conditions of continuous smoking and do not remove gaseous
pollutants from the air.
d. Morgan13 concluded that ventilation cannot solve the smoke problem, because air
in rooms forms stable layers, with gases and particles accumulating. To remove
traces of smoke, air would have to be completely exchanged 100 times per hour.
33
eg
i
e. Repace and Lowrey8 developed an indoor air quality standard for tobacco smoke
in the workplace. They calculated that a maximum tobacco tar concentration of .75
pg/m3 would limit carcinogenic risk to that considered acceptable by federal
regulatory agencies for environmental carcinogens. To achieve such a level would
require "impractical amounts of ventilation or prohibitive costs for air cleaning
equipment." They therefore conclude that "the only practical control measures are
complete physical separation of smokers and nonsmokers on different ventilation
systems, or prohibition of smoking in the workplace."
5. SEPARATE SMOKING AND NONSMOKING ENVIRONMENTS
The designation of a smoking room with completely separate ventilation from all
nonsmoking areas has been shown to be effective in protecting nonsmokers from ETS.',"
A greater than 95% reduction in ETS exposure has been documented." However, this
approach is impractical, impossible, or prohibitively expensive for most restaurants.
6. LEGISLATED 100% SMOKE-FREE RESTAURANTS
Based on the above analysis, this is the only practical approach that is truly effective
in protecting restaurant employees and patrons from exposure to ETS.
34
CONCLUSION
A legislated 100% smoke-free restaurant policy is the only effective way to protect
restaurant employees and patrons from the hazards of second-hand smoke:
1. A voluntary restaurant approach is ineffective because most restaurant owners will
not voluntarily prohibit smoking and because even if many do, employees will not
be adequately protected. Restaurant workers cannot easily choose to work only at
smoke-free restaurants.
2. Nonsmoking sections are not effective in protecting patrons or employees. Peak
concentrations of tobacco constituents are only modestly decreased in remote
locations and actually increased in locations closest to the smoking area. Average
concentrations are exactly the same, as are the adverse health effects for employees.
Many city councils have required nonsmoking sections in an effort to protect the
public health. Unfortunately, the scientific evidence suggests that a 75% smoke-free
policy, for example, is not better than a 40% policy from a public health perspective,
because it will not significantly reduce restaurant patrons' exposure to ETS, and will not
reduce employees' ETS exposure at all.
Local governments that truly wish to protect restaurant employees and the public
from the hazards of restaurant ETS exposure have no effective approach available,
other than to legislate a 100% smoke-free policy.
35
CHAPTER 7
CITIES THAT HAVE ADOPTED 100% SMOKE-FREE RESTAURANT ORDINANCES
At least 24 United States cities have adopted 100% smoke-free restaurant ordinances.
Table 8 lists these cities, their populations, and the date on which restaurants became or
must become smoke-free:
TABLE 8: CITIES WITH 100% SMOKE-FREE RESTAURANT ORDINANCES'
CITY POPULATION' EFFECTIVE DATE
Aspen, CO 5,049 1985
Telluride, CO 1,309 1988
Snowmass, CO 1,449 1989
San Luis Obispo, CA 41,958 August, 1990
Lodi, CA 51,874 November, 1990
Auburn, CA 10,592 April, 1991
Paradise, CA 25,408 August, 1991
Roseville, CA 44,685 October, 1991
El Cerrito, CA 27,379 November, 1991
Martinez, CA 31,808 March, 1992
Colfax, CA 1,306 March, 1992
Sacramento, CA 369,365 May, 1992
Hercules, CA 16,829 May, 1992
Palo Alto, CA 55,900 September, 1992
Walnut Creek, CA 60,569 September, 1992
Grass Valley, CA 9,048 November, 1992
Lathrop, CA 6,841 January, 1993
Los Gatos, CA 27,357 January, 1993
Visalia, CA 75,636 April, 1993
Whittier, CA 77,671 July, 1993
Oakland, CA 372,242 August, 1994
Lee, MA 7,869 1995
Lenox, MA 6,756 1995
Stockbridge, MA 2,408 1995
36
CHAPTER 8
ARGUMENTS AGAINST 100% SMOKE-FREE RESTAURANT ORDINANCES
There are essentially four arguments against smoke-free restaurant ordinances which
are consistently raised by the opponents of these ordinances. This chapter analyzes each
of these arguments.
I. Let restaurant owners decide whether to go smoke-free or not. Customers will then
have a choice of whether to eat at a smoke-free restaurant. The market is working.
Let the marketplace decide.
There are 9 reasons why this argument is invalid:
1. The market has created a society where 145 people a day die from breathing other
people's smoke, and where involuntary smoking is the number one environmental
cause of cancer (Chapter 1).
2. The market has resulted in restaurant employees having exposure to environmental
tobacco smoke which is 3-5 times higher than typical workplace exposure and 12-20
times higher than domestic ETS exposure (Chapter 2).
3. The market has resulted in restaurant air having a genotoxicity 10-100 times that
of urban air (Chapter 2).
4. The market has forced restaurant employees to be the group most heavily exposed
to ETS (Chapter 2).
5. The market has allowed restaurant owners to expose their employees to high levels
of carcinogens (Chapter 2).
6. The market has forced many restaurant employees to inhale the benzo(a)pyrene
equivalent of actively smoking 11h to 2 packs of cigarettes per day (Chapter 2).
7. The market has resulted in waiters and waitresses having almost twice the risk of
lung cancer due to involuntary ETS exposure (Chapter 3).
8. Studies of the market approach have demonstrated that only about 10% of
restaurant owners will choose to protect the public and their employees from ETS,
despite intensive educational campaigns (Chapter 6).
9. Unlike restaurant patrons, employees have no choice in the matter. Their exposure
to the carcinogens in ETS is truly involuntary.
37
r
II. Let the state pass a restaurant smoking law, not local government.
There are 4 reasons why this argument is invalid:
1. There have been several attempts to pass a statewide restaurant smoking law in
California, but the tobacco industry has successfully defeated every attempt.
2. The tobacco industry has contributed over$1.6 million to California state legislators
since 1975, including $255,150 to Assembly Speaker Willie Brown! This makes it
virtually impossible to pass a statewide restaurant smoking law.
3. The failure of the state to protect its citizens from the hazards of ETS is a poor
excuse for local government to fail to do so. Local governments have an obligation
to protect the public health, and it is their proper role and responsibility to
intervene where the state has left jurisdiction to them. Local governments, then,
must formulate policy on restaurant smoking precisely because of the state's failure
to do so.
4. By failing to take action, local governments are actually establishing a policy of
allowing the exposure of its citizens and employees to high levels of carcinogens
to be unregulated. Inaction amounts to action that will ensure that the near
doubling of lung cancer risk in restaurant employees due to ETS exposure will
continue.
III. Smoke-free ordinances will hurt restaurant business.
There are 2 reasons why this argument is invalid:
1. There is no valid evidence that smoke-free ordinances decrease restaurant sales. All
of the evidence that has been used to convince policy-makers of an adverse
economic impact has been based on evaluation approaches which are
methodologically flawed, and invalid. This type of evidence has misled policy-
makers, convincing them that a smoke-free ordinance caused a decrease in
restaurant sales when no such effect occurred (Chapter 5).
2. There is valid evidence, based on a rigorous econometric analysis, that smoke-free
ordinances do not decrease restaurant sales. The only valid evaluation approach
revealed that there was no significant economic impact of 100% smoke-free
restaurant ordinances in Bellflower, Lodi, San Luis Obispo and Beverly Hills
(Chapter 5).
38
IV. As a reasonable compromise to protect the health of nonsmokers, legislators
should increase the size of mandated nonsmoking sections, rather than ban
smoking completely.
There is 1 simple reason why this argument is invalid:
Segregation of smokers and nonsmokers is not effective in protecting the nonsmoker
from ETS:
a. After one hour of air mixing, there is little difference between smoking and
nonsmoking sections (Chapter 6).
b. Numerous studies have shown that there is very little reduction in air
concentrations of tobacco smoke constituents in nonsmoking areas of restaurants
(Chapter 6).
c. The creation of a smoking section may actually increase ETS exposure in the
nonsmoking location nearest the designated smoking area (Chapter 6).
d. Separation of smokers and nonsmokers does not reduce average concentrations of
tobacco smoke. Thus, it does not reduce the risk of adverse health effects for
restaurant employees (Chapter 6).
e. Increases in the size of nonsmoking sections do not significantly reduce restaurant
patrons' exposure to ETS, and do not reduce employees' exposure to ETS at all.
Increasing the size of nonsmoking areas is not a compromise measure, because it does
not reduce exposure to ETS, and therefore protects no one. Policy-makers who are truly
interested in protecting public health must eliminate restaurant ETS exposure completely.
The appropriate area of compromise is the time frame for phasing-in the 100%
restriction.
CONCLUSION
The 4 major arguments against 100% smoke-free ordinances are flawed. The benefits
of protecting restaurant patrons and employees from the health hazards of involuntary
smoking by eliminating exposure to ETS in restaurants far outweigh any possible costs.
39
FACT SHEET#2 (page I of 2)
HEALTH EFFECTS AND PUBLIC HEALTH IMPACT OF PASSIVE SMOKING
■ Passive smoking in the United States causes 53,000 deaths per year: 37,000 from heart disease,4,000 from
lung cancer, and 12,000 from other cancers.
ANNUAL DEATHS FROM PASSIVE SMOKING
Heart Disease
(69.8%)
Lung Cancer
(7.5%)
. 12,000
Other Cancers
(22.6%)
. try s • .
■ Passive smoking is the third leading cause of preventable death,behind only active smoking and alcohol.
It causes more deaths than AIDS, motor vehicle accidents, drugs, or homicide.
PREVENTABLE CAUSES OF DEATH
,3C 000
.00,000
m 300,000
CD
CL
= 200,000 ??`
i 100,000
f. 57,000
46 000
i,,:•. ,�•. .:,'" 71 000
23 000
0 r• :::i:h:: �;;;.:;?:;::. 9000
Smoking Akohol PASSIVE Motor AIDS HORlkidss Drugs
SMOKING A tchgls is
i
(continued on page 2)
g
FACT SHEET#1 (page 2 of 2)
■ Passive smoking is the #1 cause of environmental cancer. It causes more cancer deaths than all other
regulated carcinogens combined.
CANCER DEATHS:
PASSIVE SMOKING vs. ALL REGULATED CARCINOGENS
15700
u,000
`a
}
m
a 10,000
t
a
- a
5.000
a
000
U
QQZ yypp
591 soo IoCps 127 h so 20 10
1 Ac
to d uc = ;u o 4$
i
1
I
1
4
a
I
I .
From: Smokintt and Restaurants: A Guide for Policy-Makers
Michael Siegel, M.D., M.P.H.
UC Berkeley Preventive Medicine Residency Program
September, 1992
r.
s,
FACT SHEET#2
ENVIRONMENTAL TOBACCO SMOKE EXPOSURE IN RESTAURANTS
■ Exposure to environmental tobacco smoke in restaurants is 3-5 times higher than typical workplace
exposure, and 8-20 times higher than domestic exposure (living with a smoker).
RELATIVE ETS EXPOSURE:
RESTAURANTS vs. WORKPLACES vs. DOMESTIC
20 20
is
O
CL
X
W
-610
m
m
J
5 4
M 0
Loss RESTAURANTS Workplaces Domestic
• The most heavily exposed restaurant workers inhale as much benzo(a)pyrene (a carcinogen) as active
smokers of 1 V2 to 2 packs of cigarettes per day.
• Restaurant air causes mutations and chromosome changes at a rate 10-100 times higher than urban
outdoor and indoor air.
• Restaurant air causes mutations in genes at a rate 5-10 times higher than industrial workplace air.
GENE MUTATIONS CAUSED BY
RESTAURANT vs. INDUSTRIAL AIR
828
800
c
0
m :
u 600
ma
C �
fb
`o 400
C
V
C �
m
Q 200
U. 101 79
0 RESTAURANTS Foundries Polyurothans
Lowme Idanulacturinp
Pans
a Restaurant employees are the occupational group most heavily exposed to ETS and most likely to suffer
adverse health effects due to this exposure.
From: Smoking and Restaurants: A Guide for Polio-Makers
Michael Siegel, M.D.,M.P.H.
UC Berkeley Preventive Medicine Residency Program
September, 1992
FACT SHEET#3
HEALTH EFFECTS OF ETS EXPOSURE IN RESTAURANTS
■ In California, waitresses have the highest death rate of any female occupational r[oup. They have a 4
times higher rate of death from lung cancer and a 2 1/2 times higher rate of death from heart disease.
CALIFORNIA RELATIVE DEATH RATES:
4 WAITRESSES vs. OTHER WOMEN
3.68
3
m 2.47 2.56
Q
t2
is
m
D
WAITRESSES Other WAITRESSES Other WARRESSES Other
Women Women Women
OVERALL LUNG CANCER HEART DISEASE
■ Waiters and waitresses have a 50-90% higher risk of dying from lung cancer because of exposure to
tobacco smoke in restaurants. Involuntary exposure to tobacco smoke at work makes restaurant workers
11/2 to 2 times more likely to die from lung cancer.
RISK OF LUNG CANCER DEATH IN WAITERS AND WAITRESSES
2 DUE TO ETS EXPOSURE IN RESTAURANTS
1.7
m
Z 1.5
fr
r
G
.. 1
J
N y G Y
<r
r
0 $ 4 J f1 Y..:
--
WAITERS AND WAITRESSES Population
From: Smoking and Restaurants: A Guide for Policy-Makers
Michael Siegel,M.D.,M.P.H.
UC Berkeley Preventive Medicine Residency Program
September, 1992
A
REFERENCES
INTRODUCTION
1. 'The world cigarette pandemic,"Joan Beck, Providence Toumal, September 9, 1985.
2. Smoking-attributable mortality and years of potential life lost - United States, 1988..
MMWR 1991; 40:62-63,69-71
3. Schelling TC: Economics and cigarettes. Prey Med 1986; 15:549-60
4. Toward a Tobacco-Free California: A Master Plan to Reduce Californians' Use of
Tobacco. Submitted to the Legislature by the Tobacco Education Oversight
Committee, January 1, 1991.
5. Wells AJ: An estimate of adult mortality in the United States from passive smoking.
Env Int 1988; 14:249-65
6. Pertschuk M, Shopland DR, eds. Major Local Smoking Ordinances in the United
States. Washington, DC: US Department of Health and Human Services, 1989.
CHAPTER 1
1. The Health Consequences of Involuntary Smoking. U.S. Department of Health and
Human Services, Public Health Service, Centers for Disease Control, Center for
Health Promotion and Education, Office on Smoking and Health. U.S. Government
Printing Office, Washington, DC, DHHS Publication No. (CDC) 87-8398, 1986.
2. National Research Council,Committee on Passive Smoking. Environmental Tobacco
Smoke: Measuring Exposures and Assessing Health Effects. (National Academy
Press, Washington DC, 1986).
3. Environmental Protection Agency. Health Effects of Passive Smoking: Assessment
of Lung Cancer in Adults and Respiratory Disorders in Children. Washington, DC:
Environmental Protection Agency; 1990. Publication EPA 600/6-90/006A.
4. Wells AJ: An estimate of adult mortality in the United States from passive smoking.
Env Int 1988; 14:249-65
5. Repace JL,Lowrey AH:Risk assessment methodologies for passive smoking-induced
lung cancer. Risk Analysis 1990; 10:27-37
41
6. Steenland K: Passive smoking and the risk of heart disease. TAMA 1992; 267:94-99
7. Glantz SA, Parmley WW: Passive smoking and heart disease. Epidemiology,
physiology and biochemistry. Circulation 1991; 83:1-12
8. Smoking-attributable mortality and years of potential life lost - United States, 1988.
MMWR 1991; 40:62-63,69-71
9. National Institute on Alcohol Abuse and Alcoholism. Sixth Special Report to the U.S.
Congress on Alcohol and Health From the Secretary of Human Services. U.S. Dept.
of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and
Mental Health Administration, DHHS (ADM) 87-1519, 1987.
10. National Center for Health Statistics. Monthly Vital Statistics Report 1990. US Public
Health Service, Hyatsville, MD, 1990.
11. Mortality attributable to HIV infection/AIDS-United States, 1981-1990.TAMA 1991;
265:848-9.
12. United States Department of Health and Human Services. Healthy People 2000:
National Health Promotion and Disease Prevention Objectives. DHHS (PHS) 91-
50212, Washington, DC, 1991.
13. Gough M: How much cancer can EPA regulate away? Risk Analysis 1990; 10:1-6
CHAPTER 2
1. Sterling TD, Dimich H, Kobayashi D: Indoor byproduct levels of tobacco smoke: a I
critical review of the literature. TAPCA 1982; 32:250-59
a
2. Husgafvel-Pursiainen K, Sorsa M, Moller M et al.: Genotoxicity and polynuclear
aromatic hydrocarbon analysis of environmental tobacco smoke samples from
restaurants. Muta enesis 1986; 1:287-92 I
3. Cuddeback JE, Donovan JR,Burg WR: Occupational aspects of passive smoking. Am '
Ind Hyg Assoc Tv1976; 37:263-67 I
4. Bridbord K, Finklea R, Wa mer
J g JK et al.: Human exposure to polynuclear aromatic
hydrocarbons, in: Freudenthal RI,Jones PW, eds. Carcinogenesis,Vol. 1. Polynuclear
Aromatic Hydrocarbons: Chemistry, Metabolism and Carcino enesis. New York:
Raven Press, 1976, p.319-324.
42
5. Sterling TD, Mueller B: Concentrations of nicotine,RSP, CO and CO2 in nonsmoking
areas of offices ventilated by air recirculated from smoking designated areas. Am Ind
Hy& Assoc T 1988; 49:423-26
6. Vaughan WM, Hammond SK: Impact of "designated smoking area" policy on
nicotine vapor and particle concentration in a modern office building. j Air Waste
Manage Assoc 1990; 40:1012-17
7. Questions and Answers Regarding Eliminating Smoking in Restaurants Americans
for Nonsmokers' Rights, Berkeley, CA, February 5, 1992.
8. Repace JL, Lowrey AH: An indoor air quality standard for ambient tobacco smoke
based on carcinogenic risk. NY State T Med 1985; 85:381-83
9. Teschke K, Hertzman C,Van Netten C et al.: Potential exposure of cooks to airborne
mutagens and carcinogens. Env Res 1989; 50:296-308
10. Husgafvel-Pursiainen K, Sorsa M, Engstrom K et al.: Passive smoking at work:
biochemical and biological measures of exposure to environmental tobacco smoke.
Int Arch Occup Environ Health 1987; 59:337-45
11. Maclure M, Katz RB, Bryant MS et al.: Elevated blood levels of carcinogens in
passive smokers. Am T Public Health 1989; 79:1381-84
CHAPTER 3
1. Doebbert G, Riedmiller KR, Kizer KW: Occupational mortality of California women,
1979-1981. West T Med 1988; 149:734-40
2. Andersen AA, Bjelke E, Langmark F: Cancer in waiters. Br T Cancer 1989; 60:112-15
3. Menck HR, Henderson BE: Occupational differences in rates of lung cancer. TOM
1976; 18:797-801
4. Dimich-Ward H, Gallagher RP, Spinelli JJ et al.: Occupational mortality among
bartenders and waiters. Can T Public Health 1988; 79:194-97
5. Lynge E: The Danish occupational cancer study, in: Prevention of occupational
cancer. International symposium. International Labour Office, 1982, p. 557-568.
6. Williams RR, Stegens NL, Goldsmith JR: Association of cancer site and type with
occupation and industry from the Third National Cancer Survey interview. T" CI
1977; 59:147-85
43
i ,
7. Zahm SH, Brownson RC, Chang JC et al.: Study of lung cancer histologic types,
occupation, and smoking in Missouri. Am T Ind Med 1989; 15:565-78
8. Sterling TD,Weinkam JJ: Smoking characteristics by type of employment.TOM 1976;
18:743-54
9. Levin LI, Silverman DT, Hartge P: Smoking patterns by occupation and duration of
employment. Am 1 Ind Med 1990; 17:711-25
10. COMS II. California Occu ational Mortal it 1979-1981. Adjusted for Smokin
Alcohol and Socioeconomic Status.California Department of Health Services,Health
Data and Statistics Branch, Health Demographics Section, December 21, 1989.
CHAPTER 4
1. Shimp v. New Terser Bell 368 A.2d 408
2. Smith v. Western Electric 643 S.W.2d 10 (Mo. App. 1982)
3. Lee v. State of Massachusettsf Superior Court, Bristol County, Case No. 15385
4. Pletten v. U.S. Army. Merit Systems Protection Board, June 18, 1981
5. Vickers v. Veterans Administration 549 F. Supp. 85 (W.D. Washington 1982)
6. County of Fresno v. Fair Employment and Housing Commission 277 Cal. Rptr. 557
(Cal. App. 5 Dist. 1991)
7. Ubhi v. State Compensation Insurance Fund (Cat 'n' Fiddle Restaurant), No. SFO-
0341691 (Cal. Workers' Compensation Appeals Board 1990)
8. Kufahl v. Wisconsin Bell Inc. 6.2 Tobacco Products Litig. Rep.8.23(Wisconsin Labor
and Industry Review Commission 1990)
9. Brooks v. TWA and Liberty Mutual Insurance 76 SF 257-975 (California Workers'
Compensation Appeals Board 1976)
10. Bena v. Massachusetts Turn ike Authority, 7.1 Tobacco Products Litig. Rep. 8.1
(Massachusetts Department of Industrial Accidents 1991)
11. Toha nnesen v. De artment of Housing Preservation and Development 546 N.Y.S.2d
40 (N.Y. App. Div. 1989)
44
12. Schober v. Mountain Bell Telephone 630 P.2d 1231 (N.M. Ct. App. 1980)
13. Carlson R: Toward a Smoke-Free Workplace New Jersey Group Against Smoking
Pollution, Inc., Summit, NJ, 1985
14. Testimony of Action on Smoking and Health before Committee on Transportation
and Environmental Affairs, District of Columbia Council, April 2, 1984
.15. McCarthy v. State of Washington 759 P.2d 351 (Wash. 1988)
16. Alexander v. Unemployment Insurance Appeals Board (1980,2d Dist) 104 Cal. App.
3d 97, 163 Cal. Rptr. 411, 14 ALR4th 1229
17. McCrocklin v. Employment Development Department (1984, 2d Dist) 156 Cal. App.
3d 1067, 205 Cal. Rptr. 156
18. Appell v. Morristown Board of Education, AT C81-3036 (State of NJ Division of
Unemployment Compensation 1981)
19. Lapham v. Commonwealth Unemployment Compensation Board of Review, 519
A.2d 1101 (Pa. Commw. Ct.), 529 A.2d 1084 (Pa. 1987)
20. Daynard RA, Sweda EL,Jr.: Redressing injuries from secondhand smoke.Trial 1992;
28:50-54
21. Blum A: P.I. lawyers file several suits over secondhand smoke. Natl Law T 1990;
12:3,41
22. Marcotte P: Passive smoking claims increasing. ABA Journal 1990; 76:34-5
23. "Smoking liability scares employees,' LA Daily Toumal, November 14, 1991.
CHAPTER 5
I. Economic Impacts: Southern California Press Clippings in packet provided to
Oakland City�Council by tobacco industry lobby, 1992.
2. Economic Impacts of Local Smoking Bans: Expanded Data and Analyses in packet
provided to Oakland City Council by tobacco industry lobby, 1992.
3. Economic Im acts of Smoking Ban in Bellflower California. Analysis of Survey ata.
February-May 1991. Prepared for Mayor William Pendleton, May 16, 1991. �—
45
r
4. Preliminary Anal sis of the Im act of the Pro osed Los Angeles Ban on S ioking in
Restaurants, Laventhol and Horwath, Certified Public Accountants, October, 1990.
di
5. Glantz SA, Smith LRA: The effect of ordinances requiring smoke free restaurants on
restaurant sales in California. Institute for Health Policy Studies,School of Mecine
University of California, San Francisco, March, 1992. ,
f�
r
CHAPTER 6
1. Cooperation is Better than
-Leizislafion. Washington, DC: The Tobacco Institute•
�I undated. Information sheet.
2. Informational Packet. Involuntary Smoking. Conservation Law Foundation of New
England, Inc., 1985.
3. Davis RM, Boyd GM, Schoenborn CA: 'Common courtesy' and the elimination of
passive smoking. Results of the 1987 National Health Interview Survey.JAMA 1990;
263:2208-10
4. Jason LA,Holton EM: Attempts to establish nonsmoking sections in restaurants. Am
I Public Health 1988; 78:987
5. Lefcoe NM, Ashley MJ, Pederson LL, Kea s The health risks of passive smoking.
The growing case for control in enclosed environments. Chest 1983. 84:90-95
6. Olshansky SJ: Is smoker/nonsmoker segregation effective in reducing passive
inhalation among nonsmokers? Am T Public Health 1982; 72:737-9
7. Sterling TD, Mueller B: Concentrations of nicotine, RSP, CO and CO2 in nonsmoking
areas of offices ventilated by air recirculated from smoking designated areas. Am Ind
Hyg Assoc T 1988; 49:413-6
S. Repace JL, Lowrey AH: An indoor air quality standard for ambient tobacco smoke
based on carcinogenic risk. NY State I Med 1985; 85:381-3.
9. Vaughan WM, ,Hammond SK: Impact of "designated smoking area" policy on
nicotine vapor and particle concentrations in a modern office building. T Air Waste
Manage Assoc 1990; 40:1012-17
10. Slavin RG, Hertz M: Indoor air pollution: A study of the 30th annual meeting of the
American Academy of Allergy. Unpublished data.
11. Repace JL: The problem of passive smoking. Bull NY Acad Med 1981; 57:936-46
i
46
i
. r
12. Repace JL, Lowrey AH: Indoor air pollution, tobacco smoke, and public health.
Science 1980; 208:464-72
13. Morgan PP: Time for action on passive smoking. Can Med Assoc T 1982; 127:810-11
CHAPTER 7
1. Adapted from Maior Smoking Ordinances Requiring Certain Environments to be
100% Smokefree. Americans for Nonsmokers' Rights, Berkeley, CA, July, 1992.
2. 1990 Census of Population and Housing. Summary of Population and Housing
Characteristics. California. US Department of Commerce. Bureau of the Census.
CHAPTER 8
1. Begay ME, Glantz SA: Political expenditures by the tobacco industry in California
state politics from 1976 to 1991. Institute for Health Policy Studies, University of
California, San Francisco, September, 1991.
r
47
WORK PLACES
�r z
s
t^ w
� J Q
s
d
w
N
LL
M.z
LL
N
Ol
J
J
h
QN
ZW
LL c�
�- w
i
- I
B O Dan o
k�m Ivor W I NC7 TO JUMP I M JUST
IFOL.LOWIWo, THS NEW SMOKING CODG.
I ,
'O 0
.ar�r■rr�
ANNUAL COST TO BUSINESS
FROM ONE EMPLOYEE
SMOKING
1980 DOLLARS
Source of Costs
Absenteeism $220.00
Medical Care $230.00
Lost Earnings (Early death/disability) $765.00
Higher Insurance (Not Medical) $90.00
On job time lost from smoking $1820.00
Property damage (smoke/fire damage) $500.00
Maintenance (Smoke Damage, Litter Cleanup) $500.00
Damage to others by involuntary smoke $486.00
TOTAL $4611.00
Source: Dr. William Weiss, "Can You Afford to Hire Smokers?",
Personnel Administrators, May 1981 .
Helping you breathe a little easier
SMOKING AND BUSINESS
❖ Cigarette smoke contains over 4,700 chemicals, some of which are treated as hazardous
when emitted into outdoor air by toxic waste dumps and chemical plants. (Environmental
Protection Agency, "Indoor Air Facts No. 5: Environmental Tobacco Smoke" June 1989)
+ The average smoker smokes two cigarettes per hour,taking about 10 minutes per cigarette.
It takes only a few smokers to release a steady stream of smoke into the workplace.
(Environmental Protection Agency, "Indoor Air Facts No. 5: Environmental Tobacco Smoke" June 1989)
❖ In many industries, carbon monoxide or cotton fibers combine synergistically with
cigarette smoke to increase the risk of disease. (Prentice Hall Information Service, 1989)
4- Dr. William Weiss, Chairman, the Accounting Department at the University of Seattle
• Business School estimates that a smoker costs the employer$4,611 each year. Of these costs,
approximately $1576 would be eliminated each year (per smoker) by going smokefree:
nonhealth insurance premiums $ 90
property damage 500
maintenance 500
secondhand smoke 486
(American Lung Association, "Toward a Smoke-free Workplace," 1985)
❖ A growing number of insurance companies offer premium reductions in life, health and
fire and casualty policies to smokefree workplaces.
••• Smoking in the workplace may increase an employers workers' compensation costs. Non-
smoking employees have received settlements in workers' compensation cases based on
their exposure to secondhand smoke in the workplace. A nonsmoking waiter in Sausalito
received an $85,000 settlement in a workers' compensation case, a Wisoncsin Bell em-
ployee recieved $23,400 in workers' compensation payments.
4- There is a growing trend to eliminate smoking in the workplace. In a 1991 survey by the
Bureau of National Affairs and the Society for Human Resource Management,3470 of com-
panies had eliminated smoking in the workplace,compared to 77o in 1987,and 2% in 1986.
(The Bureau of National Affairs, "SHRM-BNA Survey No. 55 Smoking in the Workplace:1991" 8/29/91)
Compliance with workplace smoking policies is high. The BNA-SHRM'survey found that
seven out of 10 companies with smoking policies indicated that employees"rarely" (50%)
or "never" (20'/o) violate smoking rules. (The Bureau of National Affairs,"SHRM-BNA Survey No.
55 Smoking in the Workplace:1991" 8129/91)
4.92
2530 San Pablo Avenue, Suite J • Berkeley, California 94702 • (415) 841-3032 / FAX (415) 841-7702
Costs and Benerits o f
Smokin g Restrictions
in the Workplace .
An interview with Q: Is it possible to save money by restricting smoking in the workplace? M
William Weis, Ph.D., A: Yes, but obtaining data on cost savings associated with workplace smoking control
CPA, Albers School of restrictions is difficult. Most economic studies examine the excess costs borne by •� ,
Business, Seattle companies as a result of having smokers on their payrolls. Estimates of the excess annual
University cost per smoking employee vary by an order of magnitude, but even conservative estimates
arc substantial: $1,000 per smoker per year.
Q: Are employers motivated primarily by costs in implementing policies?
A: No. Employer surveys show that most workplace policies are implemented largely for
reasons unrelated to cost: to protect the health of employees and ensure a safe working
environment; as a reaction to nonsmoking employees' demands for a smoke-free working
environment; or fear of possible legal liability for illnesses caused by exposure to
environmental tobacco smoke in the workplace. Workplace smoking restrictions arc an
emerging trend of the 1980's, and arc becoming more widespread because of the knowledge
that the health of nonsmokers is endangered by the smoke of others. Because restrictions
are a relatively new phenomenon, they have not been fully evaluated.
Q: Are ltealth care costs a factor in this trend toward smoke-free workplaces?
A: Definitely. The Surgeon Gencral has identified active smoking as the Nation's single
most important preventable cause of disease and preventable death. About $16 billion is
spent each year on smoking-related medical costs—and businesses pay about 80 percent of
all health insurance premiums. Many employers are convinced that smoke-free workplaces
,:,v,.,,;,.•Y,•.T;,, provide,extra incentives for employees to stop smoking altogether, and that having more and
more nonsmokers in their work force eventually will translate into reduced health care costs
=�' • " for the company. '
l:f:•'.":4� •4.11
't;�'t.•'r'nS{•�f..Ci
Recognizing that employees of smoke-free companies overall may be healthier year-round,
" '� ? ::; t• many insurers are inclined to give those companies a break,on premiums. Some fire and
Vii?:���.•.:✓:r i�`};1r.'.:r
:.:�� :.•-:�:;:.:;-�+:. casualty companies, for example, will cut their premiums by 50 percent. New York Life -
reduces its annual premiums on commercial disability policies by $150 per nonsmoking
cmploycc. And Blue Cross-Bloc Shield of Minnesota gives a 22 percent discount on
premiums for insured nonsmokers.
Q: What are other economic motivations for employers to implement workplace
i t" " '�'•'r''' j smoking policies?
A: Smoking policies of past decades focused on preventing fires or explosions around
I`i flammable materials, and protecting machinery and products rather than protecting
employee health. Similarly, employers with office smoking policies today realize cost
savings because computer equipment, furniture, carpets, and other furnishings last longer in
Smoking a smoke-free environment with less maintenance.
Policy:
Questions Q: Obviously, the rewards of implementing a policy can be great—but at what cost to
the employer?
and A: Implementation costs depend on the characteristics of the company. Variables include
Answers the size and layout of the physical plant, the number of employees, and the type of policy
desired. Support for employee cessation programs, hiring a policy consultant, and public
No. 4 in relations and education costs arc all real expenses to management. However, cost savings to
a series employers from reduced ventilation system energy demands and other factors may
counterbalance these expenses.
Q: What is the effect of smoking Government's Office on Smoking and
restrictions on labor productivity? Health, found that a majority of both
A: Some people argue that workplace smokers and nonsmokers regard
policies can lower productivity because of environmental tobacco smoke as a health
excessive employee smoking breaks. hazard. In addition, a vast in of °
However, to the extent that these policies nonsmokers and almost half of current
tend to aid many employees in successfully smokers report that they are annoyed by the
quitting, it is likely that labor productivity cigarette smoke of others. Therefore, many
increases through reductions in absenteeism employees prefer not to be exposed to the
and turnover and through increased smoke of others and likely would view a
productivity of these workers. That's nonsmoking environment as a job benefit.
because smokers are absent from work 50 The company profits from improvements in
percent more often than nonsmokers, have
twice as many on-the-job accidents, and are employee job satisfaction, the ability to
• 50 percent more likely to be hospitalized recruit healthy, highly motivated employees,
than workers who do not smoke. and a general polishing of "corporate
Furthermore, nonsmokers formerly bothered image:
by coworkers' smoke may also be happier, For more information about tobacco use and
healthier, and more productive. advice on smoking cessation, call the ...
Q: Does a nonsmoking environment Cancer Information Service at
appeal to most employees? 1-800-4-CANCER (in Hawaii on Oahu call
524-1234; call collect from neighboring
A: Without question. The 1986 Adult Use islands).
of Tobacco Survey;conducted by the
TIONAL This Q&A sheet was produced by the National SMOKING TITUTE Cancer Institute in cooperation with the Smoking POLICY
Policy Institute (P.O. Box 20271, Seattle, INSTITUTE
M
WA 98102, phone 206-324-4444).
Safeguarding Workplace
uardin the Wor
g . p
eat azar s o
- Secondhand S
Stanton A. Glantz and Richard A. .Daynard
onsmokcrs who think they sivc chemicals that collect in the small to eliminate it from indoor cnviron-
have been injured by sec- air sacs in the lungs where blood absorbs ments by filtration or ventilation. In-
ondhand smoke may be the oxygen from air.These compounds dam- deed,in modern office buildings where
next big wave of tobacco age the air sacs.When absorbed into the the air is recirculated to conserve energy,
plaintiffs. This article explains why cn- blood and transported to other parts of the ventilation system spreads careino-
vironmental tobacco smoke poses health the body, they can induce a variety of gens and toxins from the tobacco smoke
hazards that cannot be ignored. diseases. throughout the building.' Even if one
A burning cigarette is a small chemical cannot smell the tobacco smoke, the
factory that fills the air with more than Involuntary Smokers levels of carcinogens and other toxins
4,000 chemicals. Among them arc 43 The smoker is not the only person can be hundreds of times above what
known carcinogens and over 400 other who inhales the thousands of chemicals would normally be.found in outdoor air.
toxins,including nicotine,an addictive in cigarette smoke.A lit cigarette spends According to the U.S. Surgeon Genet-
drug. about 90 percent of its time idling rash- al's 1986 report on the health eonse-
Cigarette smoke is a complex mixture cr than being actively inhaled.Sidestrcam qucnces of involuntary smoking, "The
of hot gases and particles of various sizes. smoke from the lit end of the cigarette simple separation of smokers and non-
One gas is carbon monoxide—a colorless, pollutes the air surrounding the smoker. smokers within the same air space may
odorless poison that binds to hcmoglo- The combination of sidcstrcam smoke reduce, but does not eliminate, the ex-
bin, the oxygen-carrying clement in red and exhaled mainstream smoke is known posure of nonsmokerz to environmental
blood cells,and reduces the blood's abil- as secondhand smoke or environmental tobacco smokc.."2
ity to carry oxygen. tobacco smoke(ETS). Nonsmokers who
Large particles, collectively known as breathe ETS arc called passive smokers Health Effects
"tar," gravitate to branching points in or involuntary smokers. The World Health Organization rc-
the lungs much as debris collects in a When the cigarette is not being smoked, ccntly issued a conservative summary of
stream at branching points. These tars it is burning at a low temperature.This the proven health effects of exposure to
contain many of the carcinogenic com- leads to much dirtier combustion than ETS:
pounds in smoke that increase the risk when a smoker is sucking on the ciga-
of the smoker's developing lung cancer. rctte, drawing oxygen through the lit Respiratory symptoms,signs and
Smaller particles also contain carcino- end and increasing.thc burning temper- function:ACUtc respiratory illness in
Sens as well as many itzirants and corro- ature.Hotter fires bum cleaner and pro- early childhood; chronic cough,
duce less air pollution. Because side- pWcgm,and wheeze in children;chron-
Stanton A. Glantz it prmfessor of medicine stream smoke is produced with dirty is middle car effusions in children;re-
at the Univcni o G i is San Fmrxu- combustion and does not have the ben- Lion i leads and growth lc lung func-
tY f � Lion in children;reduced levels of lung
co.Richard A.Daynanl,a prvfctrorat North- edts of being filtered by the cigarette it-
function in adults;increased bronchial
cac m University School of Lam, Boston, self, it is much dirtier than the main- hypcncsponsivcness(asthmatics);in-
chairs the Tobacco Products Liability Project stream smoke that the smoker inhales. creased symptoms and decreased level
acrd edits the Tobacco Products Litigation Tobacco smoke is such a complicated of lung function in asthmatics
Reporter. pollutant that it is virtually impossible Irritant cffccrs:Eye,nose,throat
TRIAL JUNE 1991 37
• Malignancy: Lung cancer search Council of the National Academy cer relationship. (Meta-analysis combines
• Childhood development: Low of Sciences,along with similar authori- the results of earlier epidemiological
birth weight;slowed lung maturation; tics elsewhere in the world, issued re- studies to increase the statistical power
decreased attained height. ports that year concluding that ETS did and accuracy of results.) Wald stated,
Furthermore,individuals with prc- indeed cause lung cancer.a
' existing health conditions, such as tifi Non-smokers who arc exposed to en-
as clash between the scientific con- vironmcntal tobacco smoke absorb
asthma,bronchitis,cardiovascular da
sensus on the effects of ETS and the
case,rhinitis,colds,and allergies,often , tobacco products into their blood and
report more severe injuries due to sec- tobacco industry's worldwide di'sinfor- tissues,and their urine contains chemi-
ondhand smoke than do healthy adults. mation campaign on the issue produced cals that arc mutagenic,that is chcmi-
It should be remembered that non- a major legal confrontation leading to cats that can induce change in the ge-
smokers arc also exposed to the same a landmark opinion this past February. nctic material in a manner that is
occupational agents as arc smokers. On July 1, 1986, the Tobacco Institute thought to be fundamental to the ini-
Certain chemicals in ETS may interact of Australia(ITA)ran an advertisement tiation of cancer.It is known that ac-
with other workplace toxins such as in several Australian newspapers similar tive smoking causes a strong effect in
asbestos thereby endangering the non- to ads that many multinational com- which thc.risk of lung cancer is some
smoker. ETS substantially augments 14 times that in non-smokers.It is the
already existing indoor air pollution panics were running in the United States accepted scientific view that exposure
concentrations of RSP,benzene,acro- to carcinogens does not have a thresh-
lein,N-nitrosamine,pyrene, nitrogen old below which there is no effect and
oxides and carbon monoxide. Thus thcrcforc one would expect that non-
the effects of tobacco on health are The smoker is not the only smokers who inhale environmental
often superimposed on the health cf- person who inhales the tobacco smoke would have at leapt
fccts of certain working conditions, thousands of chemicals in some increased risk of lung cancer.
making their cumulative effects even cigarette smoke. The conclusion that the excess risk is
more dramatics of the order of 30-50 percent is plau-
sible in the Gght of the much higher
Even this extensive list is incomplete. risk of lung cancer due to active smok-
Over the past 10 years an increasing num- and elsewhere.The Australian ad stated ing. Given all the evidence I believe
bet of epidemiological studies of the that"there is little evidence and nothing that the conclusion that breathing other people's smoke is a cause of lung
health consequences of ETS.exposure which proves scientifically that cigarette cancer is scientifically sound.12
have yielded positive results.Reccnt medi- smoke causes disease in non-smokers."
cal literature suggests that brain tumors, The Australian Federation of Consumer Morling summed up the scientific dem-
cervical cancer,,and cardiovascular dis- Organizations (AFCO) demanded that onstration this way:
ease—all potentially fatal—can also be TIA retract its statement and agree Once it is accepted:
caused by exposure to secondhand never to run it again.When the institute (a)that passive smoking involves in-
smoke.'There is a strong synergistic ef- refused,AFCO sought an injunction in halation of environmental tobacco
fect of combined radon and ETS expo- the Federal Court of Australia under the smoke which contains carcinogens;
sure in the causation of lung cancer.' Trade Practices Act to prevent TIA from (b) that there is no safe threshold
Furthermore,a fetus suffers a variety of repeating these assertions.' level of exposure to carcinogens;
harms if the mother smokes or if she is Justice T.R.. Morling heard testimony .(c)that some of the studies referred
exposed to secondhand smoke during and arguments during 91 trial days over to in the primary articles show a sratis-
her pregnancy.6 a 10-month period between November tically significant association between
Indeed, given that nonsmokers who 1989 and September 1990. Morling re-' spousal smoking and lung cancer,and
arc forced to share air space with a viewed all relevant scientific studies; (d)that dies discloses of the results
smoker end up breathing the same tox- heard 16 expert witnesses in Sydney, in sucfi studies discloses a scrtistically
significant (adjusted) risk ratio of
ins (albeit in different quantities), it is including four Americans flown in by about 1.53(Wald et al.)or 1.42(Na-
likely that all of the diseases caused by the defendant;and went to London to tional Research Council report) for
active smoking can also be contracted hear four distinguished epidemiologists— non-smokers living with smokers com-
from passive smoking. two American and two British—as rebut- pared with non-smokers not exposed
tal witnesses.10 to environmental tobacco smoke;then
Lung Cancer His 210-page opinion of February 7, my conclusion must be that there is
The best-known fatal health conse- 1991, granted the injunction." It in- compelling scientific evidence that
quence of breathing ETS is lung cancer. eluded detailed analyses of the evidence cigarette smoke causes lung cancer in
Yet the first studies documenting this relating passive smoking to lung cancer, non-smokers.13
relationship were published only 10 years as well as to asthma, middle-ear infec-
ago.' - tions,and respiratory disease in children. Heart Disease
The tobacco industry used its usual In each case,Morling rejected the resti- In terms of public health impact be-
resources—in-house scientists, press con- mony of the defense witnesses,conclud- yond lung cancer, the most significant
tacts,full-page"informational"adver- ing that there was"compelling"or even adverse health effect of ETS is that it
tisements—to deny the link. But by "overwhelming" evidence of the vari- causes heart disease in healthy nonsmok-
1986 nine additional epidemiological ous causal relationships. crs. Evidence for this is similar to that
studies had found a positive association Morling cited Professor Nicholas Wald's used in 1986 when the Surgeon General
between ETS and lung cancer.The U.S. testimony about his 1986"meta-analy- concluded that ETS causes lung cancer -
Surgeon General and the National Re- sis"of the studies of the ETS/lung can- in healthy nonsmokers.
�n -T-n TAT TT TA Tr IAA1 -
Thirteen epidemiological studies, con- kills about 37,000 each year by inducing including burning eyes,sore throat,and
ducted in a variety of locations, reflect heart disease.Estimated U.S.deaths from headache—arc all physiologic reactions
a 30 percent increase in risk of death from passivc smoking—including those from of the body to insults associated with
heart disease in nonsmokers living with heart disease, lung cancer, and other breathing in the toxins and irritants in
smokers.l' The larger studies demon- canccus—tota153,000.This makes pas- smoke.These symptoms arc the body's
strate a dose-response effect,confirming sive smoking the third-leading prevent- early warnings that ETS is dangerous—
the causal nature of the association. able cause of death,behind active smok- and can be lethal.
The epidemiological studies arc com- ing and alcohol abuse. In most jurisdictions, tobacco com-
plemented by a variety of physiological The biological mechanisms by which panics can be held strictly liable for the
and biochemical data from human studies secondhand smokc causes injuries arc foreseeable injuries their products cause
that show that ETS adversely affects similar to those observed in smokers. to innocent bystanders—thc passive smok-
platelet function and damages cells lin- Because nonsmokers' bodies have not crs. Morc than 50,000 ETS victims arc
ing Elie inside of the arteries, increasing adapted through chronic exposure to dying each year,and many more arc suf-
the risk of heart disease. ETS also rc- the poisons in cigarette smokc,nonsmok- fering serious and even disabling diseases.
duces the body's ability to deliver and crs arc more sensitive to some of the ill Lawsuits by ailing nonsmokers or their
use oxygen. effects of secondhand smoke. That is survivors may well be the next wave of
Animal experiments show that ETS not to say that passive smoking is worse toxic torts litigation. ❑
also depresses cellular respiration at the than active smoking; it is not. The ac-
basic level and accelerates development rive smoker receives a much higher dose Notes
of fatty deposits on blood vessel walls. of the toxins than the nonsmoking by- u The American Society of Heating,&frigera-
The number of deaths attributed to stander. But ETS is much dirtier than tion and Air Conditioning Engineers in Janu-
ETS-induced heart disease is about 10. the mainstream smoke the smoker in- ary 1991 withdrew its characterization of in-
door ventilation standards(ASHRAE 62-1989)
times the number due to lung cancer, hales,and even low exposures appear to as"intended to avoid adverse health effects,"
because heart disease is much more com- have a disproportionately adverse effect admitting that ventilation alone could not prc-
mon than lung cancer.Therefore,whereas on nonsmokers. vent adverse health effects from environmental
passive smoking kills about 3,700 Amcd- It is important to recognize that the tobacco smoke.
Z U.S.SURGEON GENERAL THE HEALTH
cans a year by inducing lung cancer, it nonfatal effects of passive smoking— CONSEQUENCES OF INVOLUNTARY
SMOKING 13 (1986).
3 WORLD HEALTH ORGANIZATION, .
Plaintiffs Are Winning WORLD NO-TUBACCO DAY,May 1991,at
7.
Slattery,Robison,Schuman,French,Abbott
Secondhand Smoke Cases &Overall, C!tanttr smoking and�rure to ••
Paan-c Smolt An Risk Facon for Ctrot'cal Lunar,
Most passivc-smoking complaints arc Stutz of California,277 Cal.Rptr. 557 261 J.A.M.A.1593-98(1989);Takeshi Hira-
now handled by workers'compcnsa- (Ct.App. 1991), the California Court yaa,GAncBn ing l Vo en
with H ad Baud
lion boards, but the issue is being of Appeal ruled that employees who Cohort Study in Japan,13 PREVENTIVE MED.
raised in a wide range of other con- suffer from respiratory diseases—and 680(1984);Glantz&Parnilry,Parrivr Smoking
texts as well. arc therefore particularly sensitive to � Harr Disease:Epidemiology, Plryriolgyy,and
In Ubbi v State Compc=ha n Imur- tobacco smokc—arc physically hand- Axchemirtry, 89 CIRCULATION 1 (1991).
, p,� y s Axclson,Anderson,Dcsai,Figcrlund,Janson,
aiue Fund, 0Wn Fiddle Rertaumnt, icapped under the states employment Karlsson Sc Wingren,IndoorPadon Erpxmand
No.SFO-0341691 (California Work- discr natiori statute.Employers arc Active and Paaivc Smoking in Relation to the Oc-
ers' Compensation Appeals Board required to provide "reasonable ac- curnwa of Lnng Catwer,14 SCANDINAVIAN
1990),a nonsmoking waiter alleged commodation" for handicapped .e J•WORK,ENV' 3e.HEALTH 286(1988).
that his heart attack was caused by employees. 6 John, Savitz&Sandler, Primal Exporurr to
Pa=r;'Snwk"j 0-ChiUJ;wd Gurar,133 AM.
cigarette smoke in the restaurant. In a child-custody case,SataJino v. J. EPIDEMIOLOGY 123 (1991).
The waiter,who had no previous fam- Satalino, No. 11440 786 (N.Y. Sup. 7 wed.,Takeshi Hirayama,Non-Smoking Wiry
it histo of heart of Heavy Smokers Have a Higher Risk of Lung
y ry, disease,was a�vardcd Ct.,Nassau Cty.Oct. Y0, 1990), the. Ca,rar:A Snui a n 282 BRIT.MED.
$95,000. New York Supreme Court said that yf"""I '
J. 183 (1981):
In Kufuhl v Wurmuin Bell, has., the health risk posed by secondhand 8 U.S.SURGEON GENERAL,supra note 2,at
No. 88-000676•(Wisconsin Labor smokc in the home was a factor that 247-52; NATIONAL RESEARCH COUN-
and Industry Review Commission "must be considered,as would alcohol CIL,ENVIRONMF,NPAL TOBACCO SMOKE
1990),a 25-year-old woman allc cd consumption for exam 1 when vices- 9 Austri.
g p p� Australial Fcd n of Consumer Otg.v.Tobacco
that her allergic reaction to cigarette ing the suitability of a household Insc., 6.2 Tobacco Products Litigation Rep.
- smokc had been caused by exposure environment-in which a child is to 2.77 (1991). write Box 1162, Boston, MA'
in the workplace. The commission be placed" 02117.
concluded that her lost advancement Finally, in McKinney a A�ulerson, 10 Doctors Dimitrios T'richopoulos of Harvard,
Dwight Janerich of Yale,Nicholas Wald of the
opportunities and more limited cm- 924 F.2d 1500 (9th Cir. 1991), the University of London,and Sir Richard Doll
ploymcnt options amounted to a 25 court ruled that a nonsmoking pris- of Oxford University.
percent earning impairment and' oner'who is forccd.to share a prison 11 Aumulian Fcd'n. Complete opinion is pub-
awarded her 529,000. cell with a five-pack-a-day smoker lishcd in Tobacco Products Litigation Rep.,
In Coup o Ferries.v. Fair Em may be the victim of cruel and un- Id. at Wort 9.
� f p�- y ►i Id. ac 134.
nunr and Housing Commi Simi of the usual punishment. ❑ 13 Id at 135.
14 Sea, td., Slattery, ctA.,raps note 4.
40 TRIAL JUNE 1991
pm)was -
h water
Le of hip
inced in
in post-
le COM-
A pos-
women '
ve been
system
ause, a "
Aeling.
e Protection From atthe Environmental
e at the
e bon
less in_
Tobacco Smoke e in California
bone..
other und
n The Case for a Smoke-Free .Workplace
:yle fac-
Latter-
:s Ron Borland, PhD; John P. Pierce, PhD; David M. Burns, MD; Elizabeth Gilpin, MS;
about "
s such, Michael Johnson, PhD; Dileep Bal, MD
sure to
such as Objective.--To determine the extent of exposure of nonsmoking indoor work- by regulations at the state and local lev-
,clative ers to environmental tobacco smoke ETS according to
9uoride (ETS) g type of work-site smoking els as well as by private-sector policies.
policy,work area, workplace size, and demographic characteristics. By 1989,45 states had laws restricting
ice that Design and Participants.—Participants included 7162 adult, nonsmoking, smoking in public places.In 17 of these
01 ppm indoor workers who were interviewed as part of the 1990 California Tobacco Sur- states,some restrictions were extended
in the vey. Respondents were asked whether anyone had smoked in their work area to private-sector workplaces.' In a de-
Nomen, within the past 2 weeks. tailed review of local ordinances in 1989,
fect has Results.—An estimated 2.2 million California nonsmokers were exposed to to- Pertschuk and Shopland6 identified a to-
tal of 397 city and county smoking or-
i fluori- bacco smoke at indoor work sites in 1990.Nonsmoker exposure to ETS was 9.3% tal of 397 city and county smoking or-
her re- for those working in a smoke-free worksite,23.2%for those working where there fifth ofthe total populaapproximately
on of the United -
i risk of was only a work-area restriction,46.7%for those working where there was a policy States. Three quarters of these ordi-
luoride that did not include the work area, and 51.4%for those working where there was nances mandated the adoption of work-
.t
guide no work-site smoking policy.After adjustment for type of work area(eg,office,open P g policies; however, the
area),workplace size,and demographic factors,it was determined that nonsmok- place of t
strength h of these laws varied consider-
'; ers working where there was only a work-area ban were 2.8 times more likely to ably, from simply requiring a written
Review .be exposed to ETS than those working in a smoke-free work site In workplaces Policy to vn tually eliminating smoking
heir data, r:
si,;tance. °r with no policy or a policy not covering the work area,nonsmokers were over eight in the workplace.
.; times more likely to be exposed to ETS than those who worked in a smoke These laws and ordinances have en-
-free work
site. Nonsmokers who were 18 to 24 years of age, male, or Hispanic co
, and those u aged and supported initiatives by
falth and private businesses to restrict smoking at
;; with less than a high school education had more exposure to ETS.
�� the work site.' Employers have many -
Smoking Conclusion.—These results indicate that adequate protection of nonsmokers reasons (eg, medical, legal, legislative,
Iinthree _ from ETS exposure requires a smoke-free work site.
19-1625. and economic)for taking the initiative on
e ernlog (J WA.1992;263:749-752) workplace smoking policies.'The likeli-
3.904. i .
ker DJP. �> hood that private industry would take a
•e of the SMOKING in the workplace has become have been increasingly documented.Re- workpl cer increased bw when data sho wed om the
Health. ,* an important public health issue in recent search has shown that ETS increases the that the simple separation ofsmoldngand
hdtWy years as the health effects of exposure to nonsmoker's risk of getting both lung nonsmoking indoor workers who use the
r environmental tobacco smoke (ETS) cancer','and heart disease'as well as a same air space fails to eliminate the ex- -X
h. Ain! range of respiratory illnesses.These data posure of nonsmokers to ETS.1•1
Kari T. * . culminated in the Environmental Protec- The Bureau of National Affairs,Wash-
From the Center for Behavioral Research in Cancer,
and the Victorian Anti-Cancer Council, Melbourne, victoria, tion Agency isstung.a draft report that ington, DC, conducted two surveys of
maity of �. Australia(Dr Borland);the Center for Population Stud- identified ETS as a class A (known hu- workplaces and estimated that 54g'o of
:413-420. ! ies for Cancer Provenlion,Cancer center(Dr Pierce mall)carcinogen ill 1990 4
aurancni and Ms Gilpin), and the Division of Pulmonary and Companies ill the United States had -
Buorid:: ,„ Critical Cafe Medicine(Dr Burns),University of Califor- AS tl]IS CVIdCnCC accumulated smoking policies in 1987.However,con-
nia.San Diego;and the Tobacco control Section,Cal- throughout the 1970s and 1980s,it was fidenee in the precision of this estimate
t;Jacob- ifornia Department of Heall Services, Sacramento accompanied by considerable social ac-
JAAf.t. (Drs Johnson and Bt o' is low because of a poor response rate?
tion in the United States that was aimed Data from individual employees' per- I~
Reprint requests to Population Studies for Cancer
, 'rPrevention,Cancer Center,University of California,La at regulating tobacco use in public spectives on workplace policies are avail-
. Jolla,CA 92093-0901(Dr Pierce), places?This action has been manifested able from the 1986 Adult Use of Tobacco
on et al JAMA,August 12, 1992—Vol 268,No.6
r.7
X, Environmental Tobacco Smoke—Borland et at 749
11
60 60
i
�I
0
t 50 - -- -- _ - --- - -- x vi 50
~ .G
1 t7u
40 —
ur .. °n 30 --
o. 30 ------ - ------ ,
X h , � S, w V
f a 20 - -- ------- 'sp 5�X - r o
N 10 - 13. c 10 r Z sr r,ytk { t��'�1, 4,+ ; �'a Z
yTrM� _� �� ',�l, .
} . i a`.?I+`fY 0 1
' 0 Private Shared Open Open No <50 250
Smoke-Free Work Area Limited None
Partition Regular No.of
I I Extent of Work Site Smoking Ban Type of Work Area Employees
II
Fig 1.—Exposure of nonsmokers to environmental tobacco smoke(ETS)by type Fig 2.—Exposure of nonsmokers to environmental tobacco smoke(ETS)by
of work-site smoking policy. type of work area and size of workplace(number of employees). -
Survey:45%of employed adults reported ting behavior;knowledge and attitudes the smoking policy for indoor public or
some restrictions at their place of work; about the health risks associated with common areas such as lobbies, rest
however, only 3%reported a total ban smoking; smoking in the workplace; rooms,and lunchrooms?"and"Which of
on smoking at work.'' smoker and nonsmoker activism; atti- the following best describes the policy
Previous studies evaluating work-site tudes and opinions concerning public pol- for areas in which employees work?"
smoking policies have mainly focused on icy;and media exposure to public health Response choices included the follow-
the influence of these policies on smoking messages and tobacco advertising. Us- ing:(1)not allowed in any;(2)allowed in
behaviorrather than on exposure to ETS. ing a stratified random-digit dialingtech- some;and(3)allowed in all.On the basis
Several studies have shown that smokers nique,Z0 the head of household in 32135 of the answers to the above questions,
1 smoke less when work-site smoking bans homes (response rate, 75.1%) was sur- respondents were categorized into the
l are introduced.""' Although increased veyed briefly(in either English or Span- following four groups: (1) smoke-free
quitting had been found in some ish) to enumerate household members work site (smoking banned completely
studies,"3`-"in at least one study it was and determine the smoking status of in both public and common areas and in
not seen.12 Also,some researchers have each household member. From this in- work areas); (2) work-area ban only
suggested that a strong work-site smok- formation,all adult household members (smoking allowed in some or all public or
ing policy may discourage smoking up- (at least 18 years of age)who were re- common areas but completely banned in
take among young people just entering ported as having smoked within the past work areas);(3)other limited ban(smok-
the work force.10•11,1119 After implements- 5 years were scheduled for an in-depth ing not completely banned in work ar-
tion of a smoke-fi•ee policy at one institu- interview,as were 28%of nonsmokers eas); and (4) no restrictions. Respon-
tion, the concentration of vapor-phase (response rate,75.3%of those selected). dents were included in the no-restric-
nicotine decreased significantly in all Of the 24 296 respondents, 16197 were tion category if they answered no to the
work areas and public areas except rest employed outside the home; 11704 re- first question(whether there was a pol-
rooms." However, little is known con- ported that they worked primarily in- icy)or if they answered yes to the first
cerning the effect of work-site smoking doors,of whom 7301 were nonsmokers. question but said that smoking was al-
policies on ETS exposure in nonsmokers In this article,we confine our analysis to lowed in all areas in responding to the
in the general populaton. these nonsmoking indoor workers.Sur- second two questions(extent of restric-
In this study, we investigate the re- vey respondents were weighted to ad- tion).
lationslip between the level of the work- just for probability of selection,and the Respondents were asked the follow-
site smoking policy and ETS exposure weights were ratio-adjusted to ensure ing question about their usual work area:
among nonsmoking indoor workers in that the sample was representative of "Which of the following areas best de-
California in 1990 and whether ETS ex- the 1990 California population (as as- scribes the areas in which you do most
posure is related to sociodemographic sessed by the 1990 census)by age,sex, of your work?" Response choices in-
variables. county/region,education,and race/eth- eluded the following:private office with
nicity. Details of the survey design, a door,shared office(two to four people)
j METHODS weighting, and variance estimation with a door,open area with partitions,
The study population was derived methods are given in a,report available open area without partitions,no regular
from persons interviewed as part of the from the state of California 21 work area,and other type.Exposure to
1990 California Tobacco Survey carried Whether smoking was restricted at ETS was assessed with the question,
out from July 1990 through February the respondents'work site was assessed "During the past 2 weeks has anyone
1991.This study was commissioned by using the following questions:"Doesyour smoked in the area in which you work?"
the state of California to obtain infor- employer have an official policy that re- Smoking status was assessed accord- «�
oration on cigarette smoking prevalence stricts smoking in any way?"If the an- ing to the standard questions for the ,
and other tobacco use;long-and short- swer was yes,the person was then asked, United States:"Have you ever smoked
term smoking history, including quit- "Which of the following best describes 100 cigarettes?"(ever smoker)and"Do
750 JAMA,August 12, 1992—Vol 268,No.6 Environmental Tobacco Smoke—Borland et al _
�1
11
I
I
you,smoke,how?" (current smoker).'-'-241 Table 1.-Demographic Variables and Nonsmok- Table 2.-Logistic Regression Analysis of Non-
Those answering no to either question ers'Reported Exposure to Environmental Tobacco smokers'Likelihood for Exposure to Environmental I,
were considered nonsmokers. smoke(ETS)` Tobacco Smoke"
We report the weighted population es- Exposed to ETS,% Adjusted Odds
timates only; the figures and tables in- Demographic (95%Confidence Ratiot(95
Category No. Interval) Variable Confidence Interval) !
elude the 95%confidence limits for all the tent of smoking ban
percentages and odds ratios.' Multiple Overallt 71sz zs.z (z7.a-31.0) Extent 1.0
logistic regression was undertaken to as- sex Work-area ban 2.81 (1.92-4.12) H
M 3183 35.8 (32.7-38.8) Limited ban 8.57 (5.66-12.98) iI
sess the odds ratios for the different in- F 3676 z2.s (zo.s-2s.o) No ban 8.46 (5.51-12.99)
dependent variables of interest while ad- Age y No,of employees
justing for other factors related to the de- 18-24 1192 41.9 (37.1-46.7) <50 1.0
pendent variable.' Variance estimation 2-25 5970 26.4 (24.5.28.3) work 0 .77 (0.60.0.97)
area
was based on the jackknife procedure., Education,y Private office 1.0
<12 400 43.1 (33.9.52.3) Shared office 1.48 (0.83-2.63)
Partitioned area 1.58 (1.16.2.16)
RESULTS 12 1893 33.9 (30.4-37.4) Open area 2.71 (1.63.2.96)
13.15 2406 30.1 (26.9-33.3) No regular area 2.21 (1.85-3.99) �I
ETS Exposure Among Nonsmokers Sex
z16 2553 18.6 (16.9-20.3) M 1.0
Overall, 29.2% of nonsmokers who Race/ethnicity F 0.53 (0.43-0.64)
worked indoors r'ep0rted ETS exposure White 5126 26.1 (24.3-27.9) Age,y
at the work site, which represents Hispanic toes 40.0 (34.8-45.2) 18-24 to
2-25 0.66 (0.51-0.85)
2220513 Californians. Figure 1 shows African American 355 22.7 (15.1-30.3) Ethnicity
that exposure to ETS is related to the Hispanic 1.0
Asian and other 584 28.7 (23.4.34.0)
type of work-site ban reported to be in Non-Hispanic 0.83 (0.68-1.01) I I!
"Numbers are weighted Education,y
effect. Only 9.3%of nonsmokers work- g percentages.
tRespondents with complete data for all variables in <12 1.0
- ing at a smoke-free work site reported table. 12 0.90 (0.52-1.57)
ETS exposure. This percentage in- 13-15 0.85 (0.51-1.42) II creased significantly to 23.2%for those probably more likely to work in private z-16 0.57 (0.32-0.99)
reporting a work-area ban only (95% offices and thus have more control over "A total of 7002 respondents with complete data for
all variables.
,confidence intervals do not overlap),fur- their immediate environment. Younger tOdds ratios for each variable were adjusted for all
ther increased significantly to 46.7%for workers and minorities might be more other variables in the table.
those reporting a limited ban, but did fikely to work in open work areas or for
not increase significantly at the next smaller firms. Thus, to clarify whether just greater than 1). Educational level
level(51.4%for those reporting no ban). the above trends are real and not due to was significant, but only workers who
The type of work area was also related confounding with other variables,we per- were college graduates had significantly !
to the level of ETS exposure(Fig 2).Ex- formed a logistic regression analysis us- less exposure than those who did not
posure was lowest for those working in a ing ETS exposure among nonsmokers as finish high school,and even for the col-
_pr ivate office(19.1%)and was especially the dependent variable. lege educated,the 95%confidence limit
high among those with no regular work almost reached 1. !!
„area(49.2%).The size of the workplace Multivariate Analysis of !i
also was related to exposure to ETS;ex- Exposure to ETS COMMENT
posure was 33.8%among those working Table 2 shows the adjusted odds ra- In 1990 in California, nonsmokers
in companies that employ fewer than 50 tios from the logistic regression for non- working in smoke-free work sites were
people but only 24.8% among those in smoker ETS exposure for each variable less than half as likely to report being
larger workplaces(Fig 2). adjusted for all the other variables in exposed to someone smoking in their 'I
Exposure of nonsmokers to ETS is the table. work area than those in workplaces with
shown for demographic subgroups in Ta- As expected,exposure of nonsmokers a policy that applied to work areas only.
ble 1. Men report more ETS exposure to ETS was highly related to the extent A nonsmoker in a work site that does
than do women(35.8%vs 22.9%);work- of the work-site smoking policy.Workers not ban smoking in work areas was more
ers under 25 years of age report more in a company with a work-area ban had than eight times more likely to be ex- -•
ETS exposure than do older workers adjusted odds of ETS exposure of 2.8 posed to ETS than was a nonsmoker in
(41.9%vs 26.4%);and Hispanic workers times those who work in smoke-free work a smoke-free work site.The odds of ex-
report a much higher level of exposure sites, and the odds increased greatly to posure to ETS differed very little be-
(40.0%) than do other ethnic/racial about 8.5 for those in workplaces with a tween work sites with no policy restrict-
groups.In addition,the rate of ETS ex- limited policy or no policy at all.Also,ETS ing smoking and work sites with only a
posure decreases with increasing edu- exposure was related to the type of work token level of smoking restriction(ie,a
cation level; workers with less than a area:every area type but a shared office restriction that does not include the work
high school education report an expo- showed an odds ratio that was signifi- area). Thus, a limited policy offers no
sure rate of 43.1%,while only 18.6%of cantly higher than a private office.Large advantage over no policy at all.
those with at least a college education workplaces (ie, at least 50 employees) Furthermore, after adjustment for
report ETS exposure. were also significantly related to ETS ex- type of work area,size of the workplace,
The increased exposure to ETS re- posure,but not as strongly as the other and the extent of the ban,workers 18 to
ported by men, younger workers, His- workplace variables. 25 years of age,males,and those who did
panics, and those with less education Women and older workers had lower not finish high school(compared with col-
could be confounded with the differential odds of ETS exposure (0.53 and 0.66, lege graduates)were significantly more
distribution of these workers by the ex- respectively)than did men and younger likely to report exposure to ETS.In ad-
tent of work-site policy,work-area type workers.Lower exposure odds for non- dition,there was a trend for Hispanics to
(office, open area, etc), and workplace Hispanics (O.S3) were only of marginal experience more exposure to ETS. For j
size.For instance,college graduates are significance(upper 95%confidence limit industries and other institutions in which
i
JAMA,August 12, 1992-Vol 268,No.6 Environmental Tobacco Smoke-Borland et al 751
:1
the employees arc likely to be in these de- work area during the 2 weeks before the work-site smoking policy,compared with
II mographic groups, high priority should survey.Violations ofsmoldngrestrictions only 45% nationally in 1986.9 In addi-
•.; be given to establishing ordinances man- may be caused either by visitors who are tion,according to the 1987 National Sur-
dating smoke-free work sites. unaware of the smoking*policy or by vey of Worksite Health Promotion Ac-
n In the past, the call for smoke-free workers who smoke who may not luiow tivities,"40%of employers indicated that
work sites has been justified because about the ban, may not understand its they implemented a work-site policy sim-
ventilation systems usually are not able provisions,or may not think that defying ply to comply with regulations, which
to satisfactorily extract ETS from the the policy Nvill lead to adverse copse- has important iliiplications for tobacco-
1 air of a smoking section before it is re- quences.Certainly,a smoke-free policy is control activities.
circulated through the nonsmoking sec- much less open to interpretation and Our data indicate that the only way to
tion r The present study underestimates probably more readily enforceable than a protect nonsmokers' health is with a
the extent of nonsmoker exposure to less restrictive policy. Previous studies smoke-free work site.The available ev-
ETS because of this recirculation prob- have shown that how a policy is imple- idence indicates that bans are accepted
lem as well as the exposure of employ- mented is very important to its by smokers once the bans are imple-
ees to ETS in common or public areas success.18-11 Finally,the questions asked mented."Although these facts alone will
and potential recall bias by survey re- in the survey may not have fully charac- motivate many employers to take fur-
spondents.Thus,our results present an terized the policy at the respondent's ther action,we also must work toward es-
even stronger case for the demand for a work site. tablishing local smoking ordinances that
I !I smoke-free work site: Many more California indoor workers require smoke-free work sites to protect "
i Over 90%of nonsmokers in smoke-free (smokers and nonsmokers) in 1990 the health of nonsmoking workers.
work sites were protected from ETS ex- worked in a smoke-fi•ee work site(35.9%)
posul•e.However,9%of those working in than was reported for such workers for This study was supported by contract 89-97872
I '1 a smoke-free work site and over 20%of the US population as a whole in 1986 from the California Department of Health Ser- '
those working under a work-area ban did (3%).1 In 1990 in California, 71.3% of vices,Tobacco Control Section,Sacramento.
report that someone had smoked in their indoor workers reported some type of
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I
752 JAMA,August 12, 1992-Vol 268,No.6 Environmental Tobacco Smoke-Borland et al
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AMERICANS FOR NONSMOKERS' RIGHTS VOLUME 12, NUMBER 1 SPRING 1993
Taking Local Action
The Occupational Safety and Health Administration
(OSHA) is likely to ultimately limit workplace smoking.
In so doing,local ordinances will probably be preempted.
In the meantime, however, the passage of strong local
ordinances will prepare communities for the regulations
once they occur, and contribute to greater compliance.
- The process of enacting local smoking ordinances
1 V i creates an educational campaign, while the ordinance
itself protects nonsmokers from exposure to ETS. Thus,
local smoking ordinance campaigns combine education
Members of the Advisory Board of Women and Girls Against and legislation(and meaningful local enforcement). The
Tobacco (WAGAT). They met in January to mobilize women following steps can help activists pass a nonsmokers'
and girls to counter tobacco industry targeting. (See page 5) rights ordinance now.
ANR Chairs ETS Group at Establishing a Coalition
Smoking ordinances,especially 100%smokefree or-
Leadership Conference dinances,often require the support of a coalition to share
the workload. ANR members, voluntary health agen-
cies, and local health professionals are good places to
Increasing the federal cigarette tax to $2.00 per pack start. Ideally,coalitions include members with a variety
was a key goal identified by anti-tobacco leaders gath- of skills, such as teachers, attorneys, business leaders,
ered in Washington,DC in January. The conference was and secondhand smoke victims. There are only two
the sequel to a similar 1989 leadership conference. At- prerequisites for membership:a commitment to protect-
tendees broke into workgroups to set goals and recom- ing nonsmokers, and a willingness to work.
mend action for a new administration and Congress. If you are interested in starting a coalition, contact
ANR Co-Director Julia Carol was appointed Co- ANR for a list of potential members.
Chair of the Environmental Tobacco Smoke workgroup
with Dr. David Burns of the University of California. Planning a Strategy
The conference,sponsored by the American Medical Lay the groundwork before going public with your
Association, the Centers for Disease Control, and the proposed ordinance. You may want to poll restaurants
Coalition on Smoking OR Health(American Cancer Soci- about a smokefree ordinance. (A few vocal restaurants
ety, American Lung Association, and American Heart can give the impression that all the restaurants oppose
Association), included advocates, educators, research- the ordinance.) Determine how many restaurants are
ers, and policy makers divided into twelve working already smokefree, and how going smokefree impacted
groups. The twelve issues included ETS, Women's Is- their business. Some coalitions poll citizens,perhaps as
sues,Children and Youth,Minority Issues, Excise Taxes, they leave supermarkets, about how they feel about
Marketing and Promotion,International Issues,and State smoking restrictions.
and Local Issues. Results will appear in a Final Report Once the coalition is ready to move forward, find a
and Recommendation From the Health Community to member of the city council or board of supervisors to
the 103th Congress and the Clinton Administration. sponsor the ordinance. Observe the council to help
In addition to raising excise taxes,there was consen- determine who might be appropriate. Ideally, sponsors
sus that reaching children is a priority in terms of both should be both committed to the issue and have a good
tobacco use prevention measures and protecting children relationship with their colleagues.
from exposure to environmental tobacco smoke. Continued,page 6
From Our Members Smokefree Music
Letters to the Editor Presidential Ethics In January, ANR announced
its national Smokefree Music
Editors' Note: Many ANR members
Smokefree Holland Project. The project is a coalition
responded to an Action Alert in the of musicians and music patrons
Dear ANR: Winter 1992 UPDATE concerning the seeking to eliminatesmokingfrom
tobacco industry's ties with several
nightclubs and other music ven-
Clinton administration appointees. The ni g
We,the only Dutch Nonsmok- following is an example of your letters. ues. The following is one of sev-
ers' Rights group, receive ANR eral articles which appeared on
UPDATE regularly. It is always Dear Mr. Clinton: the project in the national press.
interesting and gives us valuable The Project was also featured on
information about the actual situ- You are to be commended for MTV News.
ation in the U.S. For instance, your declared intention to hold
your special election issue gave us members of your administration SMOKE GETS IN
much information about the in- to high ethical standards. Safe- YOUR EYES:
fluence of the international tobacco guards against inappropriate The drums are beating just a
industry in both political parties. greed appear to be in place. May little louder. Could this be the
It's good that your organization I suggest that safeguards against end of smoke filled bars and
does everything in its power to killing also be erected. clubs? Maybe,if the Smokefree
make that clear; it helps us to do Vernon Jordan, who sits on Music Project has anything to
the same work in our country. R.J.Reynolds'Board,and Michael say about it. Organized by
With lots of smokefree greet- Kantor, a tobacco industry attor- Americans for Nonsmokers'
in s. Rights — which ran the grass
g ney,were on your transition team. roots campaign for the airline
Alfons Surely you are aware that the to- smoking ban — the project's
Dutch M.J. smoks bacco industry is responsible for goal is to convince nightclubs
Dutch Nonsmokers' Rights more than a thousand deaths each and other music venues to go
Society day in this country alone. Joseph smoke-free. So far,it has gained
Americans for Nonsmokers' Rights is a national lobbying and Stalin said that a single death is a the support Of Boys II Men,En
advocacy group protecting nonsmokers from involuntary smoking.
ANR is a registered 501(c)(4)lobbying organization under the IRS tragedy,but millions of deaths are Vogue, Linda ROristddt, john
Code. The American Nonsmokers'Rights Foundation is the 501 Lee Hooker, Richard Marx,
(c)(3)educational arm of ANR. "lust statistics." Don't be lulled by
ANR UPDATE Bobby McFerrin, and Tuck &
Executive Editor: Mark Pertschuk Statistics.
Editor-in-Chief: Julia Carol Patti. Within the past four
Art Design: Julia Carol I am aware that Jordan and
Artist: Tim Mancusi months,[some performers]have
Americans for Nonsmokers'Rights Kantor have made their contribu- even requested that their shows
Co-Director: Julia Carol tions. Nonetheless, it is obvious
Co-Director: Mark Pertschuk be smoke-free, says ANR's
Financial Manager: Len Casey the y have such e g re g ious ethical Mark Pertschuk. "We want to
Legislative Manager: Kevin C.Goebel
Education Manager: Patricia Brazil scotomata as to disqualify them
Policy Analyst: Robin Hobart q Y educate patrons, OWneTS and
Office Manager: Merry Weitzman from serving in the public inter- managers of concert halls,bars
Staff Assistants: Pat Kates,Zelma Soriano,and
Greg Heiman est. As one who voted for you, I and nightclubs so it happens as
Board of Directors a matter of voluntary OliC "
William Rothbard,President Richard Daynard am hopeful that future candidates Y P Y�
Anne Marie O'Keefe,Vice President Carol D'Onofrio Pertschuk says. "But It will ha
Dorothy P.Rice,Treasurer Peter Hanauer for appointments will be better Y P
Merrill J.Matchetf,Secretary Dian Kiser pen nationwide one way or an-
Sylvia Aguirre Patricia Lozada screened for contacts with the to-
Glenn Barr Paul Loveday other.„
Linda Benjamin-Kline Daniel Lowenstein bacco industry, organized crime
Walt Bilofsky Stanley A.Rubin
Alan Blum Robert M.Stern and the like, and once such con-
Marisel Brown Archie K.Suelzle USA Today,Thursday,Feb-
tact is discovered the candidate ruary 4, 1993
UPDATE is published quarterly by A will be rejected.
AMERICANS FOR NONSMOKERS'RIGHTS V.
2530 San Pablo Avenue,Suite J
Berkeley,CA 94702 Recycled paper For more information about the ANR
Leonard J. Gosink, MD Smokefree Music Project,contact Mark
Any portion of ANR UPDATE may be reprinted with appropriate San Diego, California or Greg at ANR, (510)841-3032.
credit to Americans for Nonsmokers'Rights.
2
NOW
Legislative Update trol ordinances, adding workplace provisions. Ordi-
nances banning or restricting vending machines passed
FEDERAL LEGISLATION in Longmeadow, Marlborough, Medfield, and West
Springfield. Other measures to protect youth passed in
Burlington, Fitchburg, Lancaster, Leominster, and
Excise Tax Increase: President Clinton and Treasury Norwood,and are under consideration in Acton,Gardner,
Secretary Lloyd Bentson are considering raising cigarette Rutland,Wellesley,Wilmington, and Worcester.
excise taxes. (See Action Alert, page 4.) Michigan: Governor Engler signed a package of
'1R4_`-KIDS: Senator Lautenberg (D-NJ) and Repre- youth access legislation, including restricting vending
sentative Durbin(D-IL)introduced the PRO-KIDS Act of machines. He also vetoed a smokers'rights bill. Genesee
1993. The bill makes federal offices, as well as agencies County is considering eliminating smoking in restau-
serving youth which receive federal funds, smokefree. rants along with proposals to restrict youth access. War-
ren eliminated vending machines except in bars.
STATE AND LOCAL LEGISLATION Minnesota: Activists are working to increase the
current cigarette tax of 43 cents per pack by a dollar.
Arizona: A bill preempting local smoking ordi- New Jersey: Activists are lobbying to raise the state
nances is being considered. It provides weak youth tobacco tax by a dollar. Senator Adler introduced a
access restrictions. Tucson and Paradise Valley elimi- smokefree restaurants bill which also repeals the pre-
nated cigarette vending machines except in bars. Pima emption of local restaurant ordinances.
County strengthened its workplace ordinance, and vot- N�,_vv ' o!-!<: Governor Cuomo has proposed raising
ers in Cottonwood will consider an initiative restricting the current cigarette tax of 39 cents per pack by 21 cents.
smoking this spring. North Carolina: A "smokers' rights" law passed.
California:Governor Wilson's proposedbudgetdoes North Dakota: Fargo, Jamestown, Mandan, and
not attack Proposition 99, but activists expect a battle Valley City eliminated vending machines except in bars.
before the budget is settled. Assemblymember Terry A bill protecting the tobacco industry from product liabil-
Friedman introduced A.B. 13,which eliminates smoking ity lawsuits was introduced.
in workplaces but preempts all local smoking ordinances. Ohio: A trial court ruled that Cincinnati's vending
The cities of Anderson, Belvedere, Berkeley, Mill machine ordinance is not preempted by state law.
Valley,and Redding passed 100%smokefree restaurant Oregon: Bend is considering eliminating smoking
and workplace ordinances. The same cities also passed completely in restaurants.
provisions to eliminate or severely restrict cigarette vend- Pennsylvania: Pittsburgh airport went smokefree.
ing machines. Smokefree restaurant/workplace ordi- Upper Darby Township eliminated vending machines
nances are pending in 13 other communities. Vending except in liquor establishments. Governor Casey an-
machine restrictions are pending in S communities. nounced his support for raising cigarette taxes.
Colorado: Activists defeated a bill which would have "I ex ll l�: A bill protecting the industry from product
preempted local workplace ordinances. liability lawsuits passed the Senate. West Lake Hills is
Florida: A coalition is forming to increase the current considering eliminating smoking in restaurants. Hous-
cigarette tax of 33.9 cents per pack by a dollar. ton eliminated smoking in shopping malls. The Dallas/
DeKalb County enacted a comprehensive Fort Worth airport commission voted to go smokefree.
smoking ordinance. Activists are fighting a premptive Utah: A bill was introduced to prohibit smoking in all
state bill. public places,including restaurants,except in separately-
Illinois: Charleston eliminated cigarette vending ventilated smoking rooms.
machines except in bars. Vermont: Representative Seibert introduced a bill
Maryland: Vending machine companies are appeal- eliminating smoking in restaurants and other public
ing a ruling that state law does not preempt Bowie and places except small,separately-ventilated smoking rooms.
Takoma Park's vending machine restrictions. Washington: Pierce and Spokane Counties are con-
o_tlhii sots: A tobacco industry bill to preempt sidering smokefree restaurant ordinances. A similar
local youth access ordinances failed in the Legislature, measure failed in King County after the city attorney
along with a tobacco industry "smokers' rights"bill. incorrectly reported that state law preempts smoking
Governor Weld's proposed budget diverts $70 mil- restrictions. State laws eliminating free tobacco sampling
lion of the new cigarette tax for non-tobacco control and prohibiting smoking in cars with children present are
programs,contrary to the intentions of the initiative. The pending.
budget now goes to the Legislature. West Virginia: Grant County enacted a comprehen-
Burlington and Hingham strengthened smoking con- sive smoking control ordinance.
Action Alert Caution on Synar Amendment
, ...
Raise Tobacco Excise Taxes The Federal Synar Amendment requires all states to
enact and enforce laws prohibiting selling tobacco to
minors—or risk losing federal funds. The amendment
The time is right for a big increase in federal and state may encourage stronger state action,but it may also give
cigarette excise taxes. ANR and other health groups are the tobacco industry enough leverage to pass bad mea-
asking for a minimum$2.00 per pack federal tax. In exit sures masquerading as good youth access bills. Arizona
polls on election day,voters indicated more support for
is already considering a dangerous Trojan Horse bill.
increasing tobacco taxes than any other revenue increase. Strong youth access bills have the following provi-
sions:
groups, including the Children's Defense Fund,
are suggesting raising tobacco taxes by a dollar or more. (1) above all, absolutely no preemption of local
Contact your U.S. Senators and Representative. (For ordinances;
help,contact Mark or Kevin at ANR,510-841-3032.) Here's (2) eliminating cigarette vending machines (not in-
how to reach President Clinton and Secretary Bentson: effective locking devices or supervised machines);
(3) no criminalization of minors (let the merchants
President Bill Clinton Lloyd Bentson
The White House Secretary of the Treasury be penalized,not the kids);
Washington, DC 20500 1500 Pennsylvania Avenue,NW (4) licensing of tobacco retailers; and
(202) 456-1414 Washington, DC 20220 (5) periodic inspections with under-age purchasers
(202) 566-2533 to monitor the law.
Urge your state legislators to exercise caution in
Especially vital are members of the House Ways and implementing and enforcing the Synar amendment.
Means Committee and Senate Finance Committee.Those
members are: New York Stadiums
House Ways&Means: Gibbons(FL);Pickle(TX);Rangel(NY);Stark
(CA); Jacobs (IN); Ford (TN); Matsui (CA); Kennelly (CT); Coyne Contracts between New York City and Shea/Yankee
(PA); Andrews (TX); Levin (MI); Cardin (MD); McDermott (WA); Stadiums allow the Parks Commissioner to remove"sign
Kleczka(WI);Lewis(GA);Payne(VA);Neal(MA);Hoagland(NE); or advertising matter...which is not in keeping with the
McNulty(NY);Kopetski(OR);Jefferson(LA);Brewster(OK);Reynolds character and dignity of the Stadium Facility."
(IL); Archer (TX); Crane (IL); Gradison (OH); Thomas (CA); Shaw
(FL); Sundquist (TN); Johnson (CT); Bunning (KY); Grandy (IA); We believe that ads which sell addiction,disease,and
Houghton (NY); Herger (CA); McCrery (LA); Hancock (MO); death are hardly dignified. Write the Parks Commis-
Santorum (PA). sioner and urge the removal of all tobacco ads:
The Honorable House of Representatives, Washington,
DC 20515
Betsy Gotbaum
Senate Finance: Moynihan(NY);Baucus(MT);Boren(OK);Bradley Parks Commissioner
; Department of Parks &Recreation
(NJ); Mitchell Pr or AR
(( ) y )' Rie le MI g ( )' Rockefeller WV ,( ) The Arsenal, Central Park
Daschle(SD);Breaux(LA);Conrad(ND);Packwood(OR);Dole(KS);
Roth(DE);Danforth(MO);Chafee(RI);Durenberger(MN);Grassley New York,NY 10021
(IA); Hatch (UT); Wallop (WY).
The Honorable U.S. Senate, Washington, DC 20510 Massachusetts'Tobacco Tax Revenue
You may also contact your Governor and state legislators to
encourage them to raise your state excise tax on tobacco. Governor William Weld's budget attempts to inap-
propriately divert$70 million of the new cigarette tax for
existing programs rather than the tobacco prevention
Pending Smoking Ordinances and control programs outlined in the initiative.
Write Governor Weld and your legislators and urge
Arizona: Cottonwood them to fund programs to prevent and reduce tobacco
California: Burlingame, Chino Hills, Davis, Los Angeles, addiction. For the name and address of Massachusetts
Madera County,Millbrae,Petaluma,San Diego,San Jose,San legislators,contact the American Cancer Society at(617)
Mateo,Santa Barbara, Sausalito, Stanislaus County 267-2650. Letters to Governor Weld may be sent to:
Michigan: Genesee County
Oregon: Bend Governor William Weld
Texas: West Lake Hills The State Capitol
Washington: Pierce County, Spokane County Boston, Massachusetts 02133
4
International Update Thumbs /Thumbs
Australia: Cricketer Greg
Mathews was fined $8,000 by the To the National Foundation for
We gratefully acknowledge the follow- Australian Cricket Board for partici- Ak Women Business Owners
k ing contributors of$100 or more since pating in an anti-smoking advertise- (NFWBO) for rejecting a donation
our last issue of UPDATE. ment. The Board's mains sponsor is
P from Philip Morris. A letter return-
American Heart John E.Jardine,Jr. Benson and Hedges cigarette brand. ing PM's check stated, "
[a] resolu-
Association &Mary A.Rose
American Israel Warren W.Jones Austria: Austria's Health Minis- tion of our Board ... prevents the
Anti-Smoking society Henry J.Kaiser,III ter,Dr.Michael Ausserwinkler, ro-
Arkansas Deptartment Joh Quentin Kansil p Foundation from accepting contri-
of Health Mrs.John Keenan posed a broad anti-tobacco educa- butions from tobacco companies."
Mr.&Mrs.Robert Ayres Francis R.Kerr,Jr. tion and policy campaign,including
Richard Bach EllenKippel
Bancroft-Whitney Co. &Ken Donohew a proposal to limit public smoking. or To Iowa Senate Republican
Warren&Margaret Ralph&Majorie Koldinger
Canada: The Quebec Court of
Barham Peter K.Lathrop Leader Jack Rife, for a plan to
Russell L.Baris Pamela&Allen Lechtman Appeals upheld the constitutional-
pp p convert a room reserved for nursing
Dr.Larry Barr Jane Levinsohn
Simi&Andy Barrad SuSu Levy ity of Canada's ban on tobacco ad- mothers in the Capitol building into
Otto Best Rodger P.Lewis,M.D. vertisin .Canadian Officials are also
Joan Beuchel Richelle Lieberman
g a smoking room. According to Jack,
William R.Bigge Christopher Lovelock encouraging the United States to "More people smoke than nurse ba-
WalterBilofsky Daniel Lowenstein match Canada's higher tobacco ex-
Jane Blumberg-Goldberg J.Russell Mann,M.D. g bies, and this would keep smokers
Joseph E.Bodovitz Merrill J.Matchett cise tax. from having to go out in the cold."
Mark Boettger Janice Maxwell
Rose-Marie Boller Mildred Mayne France: A broad national law
Mrs.Gita S.Braude David McRitchie limiting smoking in the workplace To the President and first lady
Richard Breidenbach B.Meislin
Helene&Bob Brown Mark J.Mendell and public places, including cafes for banning smoking in the
Kenneth J.& Paul J.Meyer and restaurants, went into effect
Susan E.Brown Kathleen Morrow White House,a policy announced In
Dr.David M.Brown Oliver C.Morse,Ph.D. smoothly. According to an article in January by Hillary Clinton.
Burkel Equipment Co. Hallam G.Murray The New York Times,"to everyone's
Joel T.Campbell Carol Jean Newman
Frieda Caplan, Nancy Nye surprise, no shots were fired."
Frieda's Inc. Nancy O'Connor p � To R.J. Reynolds for expanding
Daniel Cates Larue Olsen Germany: From January to Au- its Joe Camel marketing cam-
Mr.&Mrs.R.James Dr.Lavonne Painter gust 1992 German cigarette sales
Cayton Michael L.Parker g o g paign, in spite of evidence that the
Robert Clark Dorothy Rice dropped 9/o compared with the same campaign targets children as young
Francine M.Cohn Jane Ross eriod in 1991.
Daisy Cross William I.Rothbard p as three to six years.
MarietteCumutt-Zutter Lois M.Samson
&Jean-Marc Cumutt Mary Sandberg
CarolD'Onofrio Lyndon Sanders Women and Girls Against Tobacco
'j Charles Dicken Peter S.Schwedock
Marjorie Dovman John&Lynn Seirup
Mrs.Leah Rae Edleson Craig Siegel
Stanley Eisenberg John Sjogren ANR's Julia Carol is Co-Project Director for the newly formed
Jack rg Lynn smith
Mrs.Alice C.Fick David S.Smith g (WAGAT) project.Women and Girls Against Tobacco WAGAT WAGAT was
Mrs.A
Robert T.Fries Fred J.Stanback,Jr. created to counteract tobacco industry targeting of women and girls.
Dr.Kenneth H.Geiger Dr.Karl Steiner
Eric M.Gertz Robert M.Stern WAGAT's first two goals are:to help women's and girls' organizations
Alan Gleitsman Joy Stockwell divest of tobacco industry sponsorship and/or funding; and to help
Lloyd W.Graham Ronald Stovitz
John C.Gray &Danell Zeavin magazines read by young women eliminate cigarette advertising.
Randy Greenberg Peter Straus On April 7th, a press conference will unveil the three magazines
John Greenwood Archie K.Suelzle
Robert B.Griffiths Dr.Richard A.Suss WAGAT is asking to take the "Golden Handcuff Challenge" and elimi-
Jose H.Gutierrez Dr.&Mrs.Stephen Lee Taller nate tobacco ads. A second press conference,with the theme"Breaking
Joseph Hafey, Carlos&Janice Valenzuela
Western Consortium Dr.Mark Wald the Silence"scheduled April 21st,challenges women's and girls'organi-
Peter Hanauer Donald Waltman
Mr.&Mrs.James S. William Warburton zations to reject tobacco sponsorship.
E Hartzell Sean Ward Although funded in California by Prop 99,WAGAT has nine volun-
Mr.&Mrs.William Kenneth E.Warner
Hassoldt Gay Wayman teer chapters in New Jersey,Georgia,Washington DC,Illinois,Virginia,
Doug Hodges Lawrence R.Weisberg Florida,Vermont and Maryland. WAGAT is a partnership of Americans
Susan Hopkins Lucia Woods Lindley
Dr.Murray Howe Kenneth D.Woolfe for Nonsmokers'Rights,the Western Consortium for Public Health,and
Mr.&Mrs.G. Victor Zaccaglin
Tucker Ingham the California Medical Association.
-- - For information about WAGAT,contact Regina Penna-Currie,Program Man-
Our special thanks to William E.Bloomfield,
ager, Women and Girls Against Tobacco, 2001 Addison Street, Suite 200,
Sr.of WEB Service Company,whose ongoing l
k
eree California 94704-1103 or
6 support is vital to our efforts. Berkeley, Cli f r phone (510)841-6434.P
When the ordinance comes up for a hearing, orga-
nize the speakers who will testify. Limit testimony on
medical evidence—most councilmembers have heard
r ¢�` about the health effects of smoking,and you will want to
present just the most important evidence about second-
hand smoke. The two key arguments you must counter
are negative economic impact and smokers' rights. The
economic impact of these ordinances will be paramount
in the council's mind. Ideally,business leaders or restau-
rant owners can be recruited to address these concerns,
but if they can't, address them yourself. Personal expe-
rience, like anecdotal evidence from restaurant workers
Northern Califoria Teen Teachers ridicule tobacco ads. or others suffering from secondhand smoke, is the most
compelling testimony.
Teens As Teachers,developed by the American Nonsmok-
ers'Rights Foundation(ANRF)in 1986,has been funded by the Using the Media
Cancer Research Foundation of America (CRFA) to expand The media is an important part of the legislative
nationwide. CRFA is dedicated to preventing cancer through
research and education. Carolyn Aldige,President of CRFA,has process. Choose spokespeople who are articulate under
acted as Teens As Teachers' unofficial godmother, providing pressure, understand the issue, and know what issues
ongoing financial and spiritual support since 1987. the opposition will raise. Staging press conferences,
The grant permits Teens As Teachers to reach new sites. being interviewed by reporters,and writing letters to the
Potential sites include South Dakota,Kansas and Maryland.
Those interested in Teens As Teachers may contact Patricia Brazil, editor are all part of working with the media. The media
ANRF's Manager of Education Programs at (510) 841-3032. can be used to focus the debate and enlist new allies.
Ordinances, continued from page 1 Implementation
ANR can provide a model ordinance, as well as a The ordinance will normally go into effect a few
detailed rationale for its provisions. A thorough under- months after passage. This gives your coalition a chance
standing of this rationale can facilitate working with the to educate the community about the ordinance's provi-
city attorney in customizing the ordinance to the city. sions and how to get them enforced. Often, the city or
county will print a brochure educating business and
The Legislative Process citizens about the law. Media contacts developed during
The legislative process varies from city to city;your the campaign can be used for public education as well.
sponsor can help you understand your city's procedures. Just because the ordinance is enacted,effective,and
Familiarity with the process,including the mayor's pow- popular does not necessarily guarantee its success. Keep
ers and the format of public hearings, is crucial for an eye out for the tobacco industry. Although they may
planning your strategy. move on to the next community, they may stick around
Poll your councilmembers early in the campaign. to attempt a referendum campaign against the ordinance,
This can help you determine the degree of opposition you or simply to wait for a new council hostile to nonsmokers.
may face, the concerns that councilmembers may have, --------------------------------------------------------------
and where to focus your lobbying efforts. Coalition
members should visit or phone each councilmember. M e m b e r s h i p A p p I I c a t i o n
Bring literature,but not too much. Select spokespeople I want to join Americans for Nonsmokers' Rights. Enclosed are
my annual membership dues of:
who match a member's district, constituency, or tem-
❑$35 Basic ❑$20 Fixed Income ❑This is a renewal. ;
perament.Most importantly,ensure that all spokespeople
have a thorough understanding of the issues that may be Because ANR is a lobbying group,contributions to ANR are not
g g y tax deductible.
raised. I want to make a tax-deductible contribution to the American
Grass roots pressure—mobilizing constituents to Nonsmokers' Rights Foundation.Enclosed is my gift of:
speak out—is critical to demonstrating the depth of ❑$100 ❑$50 ❑$35 ❑$20(Fixed Income) ❑other_
support for the ordinance. Generating letters and phone Contributions to ANRF are tax deductible.
calls is the first step. Petitions carry much less weight. ? Name
ANR and other groups may have members who can be Address
contacted to lobby the council. Finally,contact political City state zip_
for Nonsmokers'and social clubs, business leagues, and others whose ; Suit e ericans
Berkeley,CA 94702 (510)841-5
153032 n Pablo Avenue,
endorsement can be useful.
MODEL
ORDINANCES
" ' ViO4&
Helping you breathe a little easier
ORDINANCES ELMINATING SMOKING IN WORKPLACES AND RESTAURANTS
January 13, 1993
100% SMOKEFREE RESTAURANTS AND WORKPLACES
Auburn, CA, 1991 Oakland,CA, 1992 (8/94)'
Albany,CA, 1992 Paradise, CA, 1991
Anderson, CA, 1993 Placerville,CA, 1992 (1/94)'
Belvedere,CA, 1993 Redding, CA, 1993
Berkeley, CA, 1992 Roseville, CA, 1991
Butte County, CA, 1992 Sacramento,CA, 1990
Chico, CA, 1992 Sacramento County, CA, 1992 (1/94)1
Contra Costa County, CA, 1991 Shasta County, CA, 1993
El Cerrito, CA, 1991 Solana Beach,CA, 1992
El Dorado County, CA, 1991 (1/94)' Solano County, CA, 1991 (2/97)'
Hercules, CA, 1992 Sonoma,CA, 1992
Lathrop, CA, 1991 Tiburon, CA, 1992
Los Gatos, CA, 1991 Visalia,CA, 1992
Martinez, CA, 1991 Walnut Creek, CA, 1991
Mill Valley, CA, 1992 Whittier,CA, 1991 (7/93)1°1
Novato, CA, 1992
100% SMOKEFREE RESTAURANTS ONLY
Aspen, CO, 1985 Loma Linda, CA, 1992
Flagstaff, AZ, 1992 (6/93)' Madison, WI, 1992 (7/95)'
Grass Valley,CA, 1990 Palo Alto, CA, 1991
Laguna Beach, CA, 1992 (1/95)' Ross, CA, 1989
Lee, MA, 1992 (7/95)1 San Luis Obispo, CA, 1990
Lenox, MA, 1992 (7/95)' Stockbridge, MA, 1992 (7/95)1
Lodi, CA, 1990 Tellruide, CO, 1987
100% SMOKEFREE WORKPLACES ONLY
Alpine County, CA, 1988 Orinda, CA, 1992
Clayton, CA, 1992 Pinole, CA, 1992
Colfax, CA, 1991 Placer County, CA, 1991
Lafayette,CA, 1992 San Mateo County, CA, 1991
Larkspur, CA, 1992 South Lake Tahoe, CA, 1992
`restaurant provisions arc phased in,date noted in parentheses. SMOIQFREE RMAURANrS ONLY: 14
2 workplace provisions are phased in,date noted in parentheses° smoKEFREE wORmACEs ONLY: 10
RmAURANrs&womiAs: 31
® Rx,clodpap�r CETOTAL ORDINANCES: 55
2530 San Pablo Avenue, Suite J • Berkeley, California 94702• (510) 841-3032 / FAX (510) 841-7702
�E8 2 2 1993
CALIFORNIA ToBACCO CONTROt
IN •
e
VIDE FORACTION
- .^kA,
K -
F
3
CALIFORNIA HEALTHY CITIES PROJECT
IN PARTNERSHIP WITH
LEAGUE OF CALIFORNIA CITIES
AMERICANS FOR NONSMOKERS' RIGHTS
HEALTH OFFICERS ASSOCIATION OF CALIFORNIA
AND MANAGED BY THE
WESTERN CONSORTIUM FOR PUBLIC HEALTH
The Western Consortium for Public Health is a nonprofit corporation sponsored by the Schools of Public Health and
University Extensions,University of California at Berkeley and University of California at Los Angeles.The San Diego State
University School of Public Health is an affiliate member.
... .:..'............ ....,,.....,..............._.......:....u�:,.".......,.y.....,...o.. 4�..- "_ .;a1.;m.....,�..0
III
CONSTRUCTING
A SMOKING
P
®tTIT
CONTROt
I
ORDINANCE
ELEMENTS OF AN ORDINANCE
► Ir
1,
There has been a sharp increase in the workplaces and public places.However,
adoption of tobacco control policies during their success and an increased demand for
the past decade.The labels vary: Clean smoke-free air has led to stronger,more
IndoorAir, Nonsrnokers'Rights,or Smoking comprehensive laws.
I
Policies.Some arc statutes,others arc
voluntary policies. ELEMENTS OF AN ?q
Many private employers,restaurant ORDINANCE
owners and other business owners have ► ,
voluntarily adopted non-smoking policies. Smoking pollution control ordi-
Voluntary policies,however,cannot be nances should be clear and concise in order
t
relied on for adequate protection.Not all to serve an educational function and to
facilitate implementation and enforcement.
workplaces and public places have volun- The following material reviews parts of a
tary policies,and nonsmokers may fear
retaliation if they seek a ban on smoking— proposed ordinance.Sample ordinances � 51�'�
'' pn
especially if their supery appear in Appendix E.
visors smoke.
Nonsmokers need the support of authorita-
tive regulation. TITLE
A smoking ordinance limits Although Smoking Pollution Control
smoking in workplaces,restaurants and. Ordinance is an appropriate and descriptive
enclosed public places to protect nonsmok- name,most local laws are simply tilled '
crs.The earliest local smoking ordinances Smoking Ordinance.A title like Clean ►s �� �
are now seen as both weak and narrow. IndoorAir•may be misconstrued to coverall y '�
They permitted smoking sections in most possible indoor air contaminants. ky }
h�SIrig.
environments and failed to include all yt�l`'I o
I 4
43
R= I i
I o ti a c c o 6 U li i r U l l ll 4 . u
37
+tv
FINDINGS AND PURPOSE APPLICATION TO
GOVERNMENT FACILITIES
This section of the ordinance explains 5
why it is required and what the law is The law should state expressly its
supposed to do.It should briefly present application to facilities owned or leased by
r
the latest medical evidence about passive the city,including vehicles.A city ordi- ;
smoking. Do not rely solely on sample nance does not apply to county,state or
ordinances; their evidence may be out- federal government facilities,but a provi-
dated. sion calling for voluntary compliance from
The ordinance should unequivocally these entities is often included. t
declare its purpose to 1) protect the health ,}
and welfare of the citizens,and 2) recognize ENCLOSED PUBLIC PLACES
that the need to breathe smoke-free air has There are three major areas typically
priority over the desire to smoke. addressed through smoking pollution
This section is critical because the control ordinances:enclosed public places, '
ordinance may be judged or even attacked workplaces and restaurants.Enclosed s.
by how well it addresses its purpose.As an public places are places accessible to the
example,the 1992 appellate decision in the public.This section typically lists some of
challenge of the ordinance adopted by the the facilities intended to be covered by the s.
City of Lodi held that:"With the stated law—such as retail stores,lobbies,elevators,
purposes of the ordinance,prevention of waiting areas,sports facilities and medical
fires,preservation of citizens'health offices.Often facilities already covered by +
(whether or not they object)and reduction state law,such as food markets,are in-
in air pollution in establishments serving cluded to provide a local mechanism for
food, this activity [smoking] is subject to enforcement.But this section is often not
either regulation or prohibition within the all-inclusive;any exceptions are specified.
µ police power..." Many recent ordinances completely
eliminate smoking in all enclosed public
DEFINITIONS places,without allowing designated t
Key terms used in the ordinance smoking areas.Exceptions specified in these
100 percent ordinances are tobacco
should be precisely defined to establish the
retailers,bars,private homes("except when
scope of the law and avoid misinterpreta-
tion.This is fundamental for the successful
used as a child care facility") and rooms in `
implementation.Well-written definitions hotels or restaurants rented for private
also eliminate loopholes in the law.For parties.Exempt bars may be defined as only
those not part of restaurants. (As of 1992
example,most laws exempt bars,so some
restaurants have attempted to be exempted only one California city,San Luis Obispo,
based on the fact that they have a bar bans smoking in all bars).Hotels may be
section.This problem can be solved by required to maintain a specified percentage
of sleeping,rooms as nonsmoking.
defining bar so that it does not include a
restaurant dining room.Terms with an, Until the mid 1980's most laws
obvious and narrow meaning need not be allowed smoking except in specified
defined. nonsmoking sections.Such a public policy
assumed that smoking was a normal
� = 44
U " aN ' ' ' J " u s L l a L, Lilly a )w 0 !t llly i-u l i ull o ll L U111ro I Urd illa li c e
behavior.Today,local legislation assumes calculation,and whether restaurants below
nonsmoking to be the norm.This shift in a specified size are exempt or must be
public policy makes healthier choices easier smoke-free.A requirement that restaurants `
choices. be 100 percent smoke-free is the simplest
and the easiest to enforce.Such a require-
WORKPLACES ment should rest on explicit findings that i
Ordinances which restrict or ban smoking sections and ventilation systems a
do not effectively protect nonsmokers.
workplace smoking place specific responsi-
bilities directly on employers.Employers Typical ordinances enacted during +�
must adopt a smoking policy in writing and the 1970's and early 1980's mandated r
make it known to current and prospective nonsmoking sections of between 40 and 60 ;.
—employees.The policy should cover percent and exempted small restaurants.
treatment of private offices occupied More recent ordinances have either entirely
exclusively by smokers,and should require eliminated smoking in all restaurants or
posting of appropriately-sized"no smok- enlarged the nonsmoking area.Some
ing"signs.If permitted,smoking areas ordinances phase in restrictions in gradual
must be clearly defined and, if in employee steps.Restaurant provisions are often the
cafeterias,limited in size.A separate room most controversial part of an ordinance. j
with a separate ventilation system may be
required;however,some ordinances which UNREGULATED AREAS
permit optional smoking areas state that A section that clarifies where smoking '
structural modifications are not required. is not regulated emphasizes that there is no
The clearest,simplest and most infringement of the right to privacy;only
effective workplace smoking regulations places regularly frequented by the general
ban smoking entirely, including all private public are regulated.This provision also
,M offices.Findings in die ordinance must reaffirms the right of any business owner to
support such a requirement by addressing ban smoking on his or her property.
the inadequacy of ventilation systems.
Ordinances that allow some smoking in the POSTING OF SIGNS
workplace often protect nonsmoking
employees by requiring employers to A law that does not require the
support and publicize a policy that gives the posting of signs is essentially useless.
preferences of nonsmokers precedence over Ordinances often specify where the signs
those of smokers in case of a dispute. are to be posted,what they should look
like,and what the minimum size should be.
RESTAURANTS Restaurants often have to post a sign at
every entrance clearly stating the availability
Restaurants,although they are both of nonsmoking sections.Movie theaters
enclosed public places and workplaces,arc may be required to show a"no smoking"
usually addressed separately in smoking message on the screen prior to a feature
ordinances.Restrictions which allow some motion picture.Most smokers willingly
smoking in restaurants should state the comply with"no smoking"signs that are
percentage of seating available for a prominently displayed,which minimizes
smoking section,whether seats in a the need for active enforcement.
contiguous bar must be included in that
45
I' o b a c c u is o n t r o 1 1 n t, a I i i u 11 d
li
I,
i'
ENFORCEMENT. the entirety of a problem,and therefore
ll.
Cities provide for enforcement of may regulate only some aspects of a
smoking control legislation in various ways. problem(City of New Orleans Y.Dukes,
j The usual choice is.the city manager or the 427 U.S.297,303;49 L.Ed.2d 511,96
local health department,although some S.ct.2513 (1976)),rationally-based
Ni exemptions will be upheld.
cities have chosen other departments.
Placing enforcement with the police may ,
jj give the impression that law enforcement PUBLIC EDUCATION
I'z resources are being diverted.Enforcement Provisions for a public education
lull by the health department sends the correct program can smooth implementation and
i. message that smoking is a health issue.A enforcement.Ideally begun before the
complaint mechanism for private citizens is ordinance takes effect,public information
essential,particularly for nonsmoking programs often provide,at a minimum,for
employees. distributing an explanatory pamphlet to
local businesses.The pamphlet is some-
PENALTIES times mailed with annual business license
information at little additional cost.
A fine schedule gives the enforcement
!!, agency leverage to encourage compliance.
i,
Violations are often made an infraction,the OTHER APPLICABLE LAWS
least serious category of crime.However, This provision explicitly states that -
criminal sanctions may be avoided alto- the law does not inadvertently permit
gether by providing for a civil penalty smoking in areas previously prohibited by
instead of a fine. Citations have in fact another law.
:! rarely been required.
SEVERABILITY
NON-RETALIATION
This is a standard provision to ensure
This is a common clause which
that if part of the law is struck down by the
protects nonsmokers from retaliation by courts,the remainder will remain in effect.
supervisors or employers for expressing the
right to a smoke-free environment.It is EFFECTIVE DATE
similar to many labor law provisions
lprohibiting employers from taking action Most ordinances become effective 30
against employees who report health and days after adoption.The effective date
r : safety violations.The clause explicitly should reflect the time necessary for
' protects die nonsmoking employee from adequate public education.A recent
discharge,refusal to hire,or other retalia- development is to phase in stronger
tion. restrictions with a succession of effective
dates.
EXEMPTIONS
Exemptions should be cautiously
applied.They should be health related and
tl i express their rational basis.Because a
legislative body is not obligated to regulate
li 46
a
Americans for Nonsmokers' Rights
2530 San Pablo Avenue,Suite J
Berkeley, California 94702
(415) 841-3032
MODEL ORDINANCE ELIMINATING SMOKING
IN WORKPLACES AND ENCLOSED PUBLIC PLACES
Sec. 1000. Title
This article shall be known as the Smoking Pollution Control Ordinance.
Sec. 1001. Findings and Purpose
The City Council does hereby find that:
Numerous studies have found that tobacco smoke is a major contributor to indoor air
pollution, and that breathing secondhand smoke is a cause of disease, including lung cancer,
in nonsmokers. At special risk are elderly people, individuals with cardiovascular disease,
and individuals with impaired respiratory function, including asthmatics and those with
obstructive airway disease;and
Health Hazards induced by breathing second-hand smoke include lung cancer, respiratory
infection, decreased exercise tolerance, decreased respiratory function, bronchoconstriction,
and bronchospasm.
Accordingly, the City Council finds and declares that the purposes of this ordinance are (1) to
protect the public health and welfare by prohibiting smoking in public places and places of
employment; and (2) to guarantee the right of nonsmokers to breathe smoke-free air, and to
recognize that the need to breathe smoke-free air shall have priority over the desire to smoke.
Sec. 1002. Definitions
The following words and phrases, whenever used in this article, shall be construed as defined
in this section:
1. "Bar" means an area which is devoted to the serving of alcoholic beverages for
consumption by guests on the premises and in which the serving of food is only
incidental to the consumption of such beverages. Although a restaurant may contain a
r bar, the term"bar"shall not include the restaurant dining area.
2. "Business" means any sole proprietorship, partnership, joint venture, corporation or
other business entity formed for profit-making purposes, including retail
establishments where goods or services are sold as well as professional corporations
and other entities where legal, medical, dental, engineering, architectural or other
professional services are delivered.
3. "Dining Area" means any enclosed area containing a counter or tables upon which
meals are served.
4. "Employee" means any person who is employed by any employer in the consideration
for direct or indirect monetary wages or profit, and any person who volunteers his or
her services for a non-profit entity.
-1-
5. "Employer' means any person, partnership, corporation, including a municipal
corporation, or non-profit entity, who employs the services of one or more individual
persons.
6. "Enclosed Area" means all space between a floor and ceiling which is enclosed on all
sides by solid walls or windows (exclusive of door or passage ways) which extend
from the floor to the ceiling, including all space therein screened by partitions which
do not extend to the ceiling or are not solid, 'office landscaping" or similar structures.
7. 'Non-Profit Entity" means any corporation, unincorporated association or other entity
created for charitable, philanthropic, educational, character building, political,social or
other similar purposes, the net proceeds from the operations of which are committed to
the promotion of the objects or purposes of the organization and not to private
financial gain. A public agency is not a "non-profit entity" within the meaning of this
section.
8. "Place of Employment" means any enclosed area under the control of a public or
private employer which employees normally frequent during the course of
employment, including, but not limited to, work areas, employee lounges and
restrooms,conference and classrooms, employee cafeterias and hallways.
a. A private residence is not a "place of employment" unless it is used as a child
care or health care.facility.
b. The dining area of a restaurant is not a "place of employment."
9. "Public Place" means any enclosed area to which the public is invited or in which the
public is permitted, including but not limited to, banks, educational facilities, health
facilities, public transportation facilities, reception areas, restaurants, retail food
production and marketing establishments, retail service establishments, retail stores,
theatres and waiting rooms. A private residence is not a "public place."
10. "Restaurant" means any coffee shop, cafeteria, sandwich stand, private and public
school cafeteria, and any other eating establishment which gives or offers for sale food
" to the public, guests,or employees, as well as kitchens in which food is prepared on the
premises for serving elsewhere, including catering facilities, except that the term
"restaurant" shall not include a cocktail lounge or tavern if said cocktail lounge or
. tavern is a "bar"as defined in Section 1002(1).
11. "Retail Tobacco Store" means a retail store utilized primarily for the sale of tobacco
products and accessories and in which the sale of other products is merely incidental.
l
12. "Service Line" means any indoor line at which one (1) or more persons are waiting for
or receiving service of any kind, whether or not such service involves the exchange of
money.
13. "Smoking" means inhaling, exhaling, burning or carrying any lighted cigar, cigarette,
weed,plant or other combustible substance in any manner or in any form.
14. "Sports Arena" means sports pavilions, gymnasiums, health spas, boxing arenas,
swimming pools, roller and ice rinks, bowling alleys and other similar places where
members of the general public assemble either to engage in physical exercise,
participate in athletic competition or witness sports events.
-2-
Sec. 1003. Application of Article to City-Owned Facilities
All enclosed facilities owned by the City of shall be subject to the provisions of
this article.
Sec. 1004. Prohibition of Smoking in Public Places
A. Smoking shall be prohibited in all enclosed public places within the City of
including, but not limited to, the following places, and with the
following exceptions:
1. Elevators.
2. Buses, taxicabs, and other means of public transit under the authority of the
City of , and ticket, boarding, and waiting areas of public transit
depots.
3. Restrooms.
4. Service lines.
5. Retail stores.
6. All areas available to and customarily used by the general public in all
businesses and non-profit entities patronized by the public, including but not
limited to,attorneys.' offices and other offices,banks,hotels and motels.
7. Restaurants.
.� 8. Public areas of aquariums, galleries, libraries and museums when open to the .
public.
9. Any facility which is primarily used for exhibiting any motion picture, stage,
drama, lecture, musical recital or other similar performance, except when
smoking is part of a stage production.
10. Sports arenas and convention halls.
11. Every room, chamber, place of meeting or public assembly, including school
buildings under the control of any board, council, commission, committee,
including joint committees, or agencies of the City or any political.subdivision
of the State during such time as a public meeting is in progress, to the extent
such place is subject to the jurisdiction of the City.
12. Waiting rooms, hallways, wards and semiprivate rooms of health facilities,
including, but not limited to, hospitals, clinics, physical therapy facilities,
doctors' offices,and dentists' offices.
13. Common areas in apartment buildings, condominiums, retirement facilities,
and nursing homes.
14. Polling places.
B. Notwithstanding any other provision of this section, any owner, operator, manager or
other person who controls any establishment or facility may declare that entire
establishment or facility as a nonsmoking establishment.
Sec. 1005. Regulation of Smoking in Places of Fmploym en
A. It shall be the responsibility of employers to provide a smoke-free workplace for all
employees, but employers are not required to incur any expense to make structural or
other physical modifications.
B. Within 90 days of the effective date of this article, each employer having an enclosed
place of employment located within the city shall adopt, implement, make known and
maintain a written smoking policy which shall contain the following requirements:
- Smoking shall be prohibited in all enclosed facilities within a place of
employment without exception. This includes common work areas,
auditoriums, classrooms, conference and meeting rooms, private offices,
elevators, hallways, medical facilities, cafeterias, employee lounges, stairs,
restrooms, vehicles,and all other enclosed facilities.
C. The smoking policy shall be communicated to all employees within three (3) weeks of
its adoption.
D. All employers shall supply a written copy of the smoking policy upon request to any
existing or prospective employee.
Sec. 1006. Where Smoking Not Regulated
A. Notwithstanding any other provision of this article to the contrary, the following areas
shall not be subject to the smoking restrictions of this article:
1. Bars.
2. Private residences, except when used as a child care or health care facility.
r
L 3. Retail tobacco stores.
!. 4. Restaurants, hotel and motel conference or meeting rooms and public and
private assembly rooms while these places are being used for private functions.
B. Notwithstanding any other provision of this section, any owner, operator, manager or
other person who controls any establishment described in this section may declare that
entire establishment as a nonsmoking establishment.
Sec. 1007. Posting of Signs
A. "No Smoking"signs or the international "No Smoking"symbol (consisting of a pictorial
representation of a burning cigarette enclosed in a red circle with a red bar across it)
shall be clearly, sufficiently and conspicuously posted in every building or other place
where smoking is regulated by this article, by the owner, operator, manager or other
person having control of such building or other place.
-4-
B. Every theatre owner, manager or operator shall conspicuously post signs in the lobby
stating that smoking is prohibited within the theatre or auditorium, and in the case of
motion picture theaters, such information shall be shown upon the screen for at least
five (5) seconds prior to the showing of each feature motion picture.
C. Every restaurant shall have posted at every entrance a conspicuous sign clearly stating
that smoking is prohibited.
Sec. 1008. Enforcement
A. Enforcement of this article shall be implemented by the Department of Health [or the
City Manager].
B. Any citizen who desires to register a complaint under this chapter may initiate
enforcement with the Department of Health [or the City Manager].
C. The Fire Department or the Health Department shall require, while an establishment is
undergoing otherwise mandated inspections, a "self-certification" from the owner,
manager, operator or other person having control of such establishment that all
requirements of this article have been complied with.
D. Any owner, manager, operator or employee of any establishment regulated by this
article may inform persons violating this article of the appropriate provisions thereof.
E. Notwithstanding any other provision of this article, a private citizen may bring legal
action to enforce this article.
Sec. 1009. Violations and Penalties
A. It shall be unlawful for any person who owns, manages, operates or otherwise controls
the use of any premises subject to regulation under this article to fail to comply with
any of its provisions.
B. It shall be unlawful for any person to smoke in any area where smoking is prohibited
by the provisions of this article.
C. Any person who violates any provision of this article shall be guilty of an infraction,
punishable by:
1. A fine not exceeding one hundred dollars ($100) for a first violation.
2. A fine not exceeding two hundred dollars ($200) for a second violation of this
article within one(1) year.
3. A fine not exceeding five hundred dollars ($500) for each additional violation of
1 this article within one (1) year.
Sec.1010. Nonretaliation
No person or employer shall discharge, refuse to hire or in any manner retaliate against any
employee or applicant for employment because such employee or applicant exercises any
right to a smokefree environment afforded by this article.
Sec- 1011. Other Applicable Laws
This article shall not be interpreted or construed to permit smoking where it is otherwise
restricted by other applicable laws.
Sec. 1012. Severability
If any provision, clause, sentence or paragraph of this article or the application thereof to any
person or circumstances shall be held invalid, such invalidity shall not affect the other
provisions of this article which can be given effect without the invalid provision or
application,and to this end the provisions of this article are declared to be severable.
Sec. 1013. Effective Date
This article shall be effective thirty (30) days from and after the date of its adoption, and shall
be reviewed within one year of its effective date.
t,
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I
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�r�
The Cost ot smokin
•
Ca Dana 198
g Dorothy P. Rice
Wendy Max
d.
Institute for Health Aging, School of Ni-ning
University of California, San Francesco a
l
iY
r .
' 1
t
1,
7
'.0
S
Researcb fit nded by
Tobacco-Related Disease Research Program
MM,
University of Califomia
Report production supported by
• Tobacco Control Section
California State Department of Health Services
a
Highlights
• Smoking annually imposes a multibillion dollar burden on Californians -
$7.6 billion in 1989.
• The cost of the adverse health effects of smoking annually amounts to
$256 per Californian or$1,543 per smoker.
f,. Considerable variation in smoking cost per resident (based on statistically
significant estimates) occurs among the 58 counties in California; ranging
from$172 in Lassen County to $377 in Inyo County.
• Almost 5 million people in California smoke cigarettes, including 220,000
adolescents and 4.7 million adults.
• More men than women currently smoke - 2.7 million men, .2.1 million
women, 118,000 adolescent boys, and 102,000 adolescent girls.
• Annual cigarette sales in California amount to $4.5 billion compared with ,
$7.6 billion for the cost of the adverse health effects of smoking.
• Charging California smokers for smoking-related medical costs and
productivity losses would add $3.43 to the price of each pack of cigarettes.
If smokers were taxed to cover these costs, every smoker would pay
$1,543 a year.
• The cost of smoking for men is more than twice that for women $5.4
billion compared.with $2.3 billion: The significantly higher cost for men
reflects their higher rate of smoking and illness, greater number of deaths,
and higher earnings.
• Direct medical cost amounts to $2.4 billion and comprises 31 percent of
the total cost of smoking in California; the value of lost productivity due
to smoking-related illness amounts to $860 million, 11 percent of the total;
and productivity losses for people who die prematurely amount to $4.4
billion (based on a 4 percent discount rate) or 58 percent of the total.
• Expenditures for hospital care of current and former smokers amount to
$1.6 billion or 69 percent of the total direct medical cost; physician services
amount to $427 million; nursing home care, $147 million; medications,
$129 million; and other professional services,$22 million.
• In 1989, 4207 Californians died due to smoking-related diseases, -
resulting in 643,000 years of potential life lost based on life expectancy at
death, and $4.4 billion lost to the economy of California (based on a 4
percent discount rate) or$104,484 per death.
• One of five deaths in California is attributable to smoking.
• Men account for 63 percent of the smoking-related deaths in California, 61
percent of years of potential life lost, and 72 percent of the productivity
losses.
MM
9
San Bernardino
.r
-`'
Smoking Amount Per Per
Cost (thousands) Resident Smoker
Total $364,011 $256.64 $1,307.15
Direct 97,134 68.48 348.80
Indirect 266,877 188.16 95834 .�
•� Morbidity 37,168 26.20 133.47
Mortality 229,709 161.95 824.87
Men ' $261,834 $368.36 $1,690.95
Direct 68,529 96.41 442.57
Indirect 193,305 271.95 1,248.39
Morbidity 25,979 36.55 167.78
Mortality 167,326 235.40 1,080.61
Women $102,177 $144.40 $826.45
Direct 28,605 40.43 231.37
Indirect 73,572 103.98 595.08
Morbidity 11,189 15.81 90.50
Mortality 62,383 88.16 504.58
Smoking- Amount Per Per
Attributable _(thousands) Resident Smoker
Health Total $97,134 $68.48 $348.80 "
Care Hospital 65,010 45.83 233.45
Expenditure Physician 21,434 15.11 76.97 ^
Nursing Home 4,821 3,40 17.31
Medication 5,034 3,55 18,08
Other Professional 835 0.59 3.00
Population Under 65
1990 Total 18'
18 - 34 35 - 64 and Over
Total 1,418,380 439,223 426,381' 427,876 124,900.,
Mcn 710,807 225,022 219,998 213,731 52,056
Women 707,573 214,201 206,383 214,145 72,844 •�
148
i
n Q?wj$.'•...t.r.K r.r.rvtY..v...vn....1.rn r.
:?•\`:•: v vvn. .y.tvN�:: tr..K.v.
KK,.tntY.tt.r....,...,..t vfiiv........t.t.......t.......tt,. r.n.........t.t......tKt...t.tt...ttKt.K.t..... .}:�}•.}•.Y •
;3
•A
Currently Smoke Formerly Smoked Never Smoked Smoking
Percent Percent Percent Prevalence
Number of Total Number of Total Number of Total w
Total 278,478 25.2 292,867 26.5 532,289 48.2
Men 154,844 28.1 177,258 32.2 218,108 39.6
12 - 17 10,566 16.4 15,977 24.8 37,882 58.8
18+ 144,278 29.7 161,281 33.2 180,226 37.1
Women 123,634 22.3 115,609 20.9 314,181 56.8
12 - 17 5,224 8.7 16,934 28.2 37,892 63.1
18+ 118,409 24.0 98,674 20.0 276,288 56.0
Due to Smoking Deaths
Percent
Total Number of Total
Total 9,614 2,022 21.0 "
Men 5,164 1,296 25.1
Women 4,450 726 16.3
Number Years Years of
of Years per Death Potential
Total 32,481 16.1 Life Lost
Men 20,092 15.5
Women 12,389 17.1
Amount Per Mortality
(thousands) Death Cost
Total $229,709 $113,596
San Bernardino Men 167,326 129,070
Women 62,383 85,956
149
Table 1
fi+ .
Cost of Smoking by Type of Cost and Gender, California, 1989
r
Amount Percent Per Per
Type of Cost & Gender (thousands) Distribution Resident Smoker
Total $7,633,204 100 _ 49
.0 $256. $1,543.36
Direct Cost 2,363,174 31.0 79.41
Hospital 477.81
P . 1,637,809 21.5 55.03 331.15
Physician 427,251 5.6 14.36
Nursing home 147,355 86.39
1.9 4.95 29.79
Medication 128,824 1.7 4.33 26.05
Other professional 21,935 0.3 0.74
4.44
Indirect Cost 5,270,030 69.0 177.08 1,065.55 '
Morbidity 860,060 11.3 ?
S.
Mortality* 4 8 90 1737.90
,409,970 57.8 148.18 891.65
Men, Total 5,355,044 100.0 359.46 1,923.90
Direct Cost 1,608,387 30.0 107.96 577.84
Hospital 1,266,954 23.7 85.04
Physician 20412.1 3 8 455.18
i
13.70 73.33
Nursing home 64,920 1.2 4.36
Medication 59,940 1 2 . 3
Other professional 12,454 '? 4.02. 211 3
.55
0._ 0.84 4.47
Indirect Cost 3,746,657 70.0 251.49 1,346.06
Morbidity 561,535 10.5
Mortality* 37.69 201.74
3,185,122 59.5 213.80 1,144.31
Women, Total 2,278,160 100.0
153•28 1,053.53
Direct Cost 754,787 33.1 .50.79
Hospital 370 855 349.05
16.3 24.95 171.50
Physician 223 130 9,8
Nursing home 82'36 15.01 • 103.19
3.6 5.55 38.12
Medication 68,885 3.0 4.63
Other professional 9 481 31.86
0.4 0.64 4.38
Indirect Cost 1,523,373 66.9 102.50 704.48
Morbidity 298,525 13.1 20.09
Mortality* 1,22 138.05
4,848 53.8 82.41 566.43
Note: Numbers may not add to total due to rounding.
* Discounted at 4 percent.
r
35
,i
TOBACCO INDUSTRY
TACTICS
1.
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SAvz �ra�,cisCo 'Extiw�t�C►'' �'ft fqZ
n st. Tracy Scott of the California
VU - I I Uffs
S ®� Business and Restaurant Alliance.
acknowledged the group was partly
® fmanced..by tobacco manufactur=.7n 0 _�01% ers. The group was -founded b�
� � F V Fred Kamer:vice president of l}o1�
�� phin•Media;Croup,-which
_ . TeP re-
'cents:th;6'!Pllltp,Morris tobacco.
Local politicians and health of- 'company.- J
Campaigns paid for . ficials say the tobacco industry is. But ScotCsaid most of CBRI's-.
striking down, or weakening, budget-.came .from the 300..to *"7
by cigarette makers smoking restrictions in towns -reatauranta that:ar is"'members;
and restaurants across California,usually under the - The group.' not disclose its bud=
-T- --11 guise of groups claiming to repre-`''get, rior say specificaIIy_how mucli.,
weaken Or. defeat sent local businesses. . of ita'mone'y comes-from toba.CCO i
At a press conference Tuesday, manufacturers.
clean-air•laws elected officials and representa- Steve Blanton, a councilmsri iri
tives`of eight Bay Area cities and Los Gatos,said the,group told local
By Jayne Garrison counties said "front groups" su restaurant-owners that they-would
EXAMNM"c^LT""F'Tm ported by the industry we e mov_ ' lose 30 percent.of tfieir.business if
ing into their communities with smoking was banned.in restau-
The slick IIyer depicted a burly lightning speed, and stirring fear its'
copholding a radar-like device. =- In fact,he noted,a UCSF study
"Don't turn the Sebastopol Police over smoking ordinances that ; this ear
„ would,otherwise,have passed with '° Y- Y? state;taz retards
Into The Cigarette Police, it ease and found no'`drop"in revenues ,
waru&d every registered 'voter in from cities'that banned smo
.the.aniall North Bay own, > The- induatr in
Y y-supported: restaurants.
The message and the mass mail- group. California Business and;'
ing was paid for by Californians for Restaurant Alliance, delivered fly-
Fail Business Policy, rs to Pinole restaurants asng,
cy a group fund- ki
"Do you want to lose all your busi-
�•���� manufactiizess and ness?" when that small town con- I
restaurants.And it worked.Voters, aidered a ban on smoking in restau-
by atiny margin of 5 votes,defeat- •rants Councilwoman Gretchen -
ed this year an advisory measure
recommending the City Council Mariotti said so many business .
ban smoking in restaurants and owners were terrified that the
workplac6.. council reluctantly agreed to com-
promise, and require that 60 per-.
"We worked on that ordinance. cent of all dining seats be reserved
over a year," reflected Richard for nonsmokers.
.Goldberg,director of health educa- > When the Walnut Creek City
tion for Sonoma County, "We es- Council actually adopted a similar
petted a close victory. But when smoke-free law in 1991, the same
w e lo barn industry came to fawn,' group sent letters, held meetings
and lobbied heavily until the coun-
cil this year agreed to postpone the
ordinance, Councilman Ron Be-•
agley said_
D- And when Tiburon first con-
aidered such a law this year, the
group, along with two Novato res-
taurant owners 15 miles to the
north, sent every restaurant in Ti-
buron a letter asking: "Do you
want your customers leaving
town?" Council members received
calls from Los Angeles, Sacramen-
to, Colorado and North Carolina
about the proposed law. But no
local businesses complained until
the California Business and Res-
taurant Alliance hit town, said
Randy Greenberg of the Smokefree
Marin Coalition.
i
Antioch.CA
(Contra Costa Co.)
Daily Ledger-Post i
Dispatch
(Cir.0.21,923)
p71 I JUL 1 1 1992-
P.c.it l:,,. 114J4
Smoke an : sparks
e ,
t .
r '
`CA
Staff phow/vkt-u 1"6d-
Linda Wadsworth,owner of the Buzz Inn In Oakley,signed a letter saying the smoking ban has badly hurt her bar and other businesses.
Bar's letter just a smoke screen?
By AJ.Jacobs a�f_ront �ouo f0LthLtobacco in-
in
dus l lte statistics are on
star—n" LL Restaurants that are abiding by wed studies, they say. .
OAKUY — Far East County Wadsworth acknowl e
has become another hot spot in the (smoking ban) have lost 30 to 40 restauran c t-
the swirling statewide debate over ■ to an � osta .Bur,she
restaurant smoking bans. percent of their business. /9 word of, s e agrees with every
Since the crackdown on ciga- word of it—only she wanted the
rettes in Oakley, the owner of a — From a letter sent to city ouncils let```s anti-ban Stance Stated ;n
local bar has sent a letter across Y even stronger language.
the state charging the govern- statewide "I feel wort s strong about
ment with snuffing out restaurant this."Wadsworth said,adding that
business in this town of 18,000. some of her colleagues are going
But antismoking groups say the use restaurant owners to do their state,where similar smoking bans out of business because of the ban.
letter isn't an angry grassroots re- work." are being debated. "I wish I had the time to run from
action — it's an instance of big Oakley's brouhaha is a good "Restaurants that are abiding door to door."
business meddling in politics. snapshot of the smoking ban con- by the(smoking ban)have lost 30 Wadsworth said the alliance is
They charge the powerful to- troversy in California.It has pitted to 40 percent of their business,"it not a front for the tobacco indus-
bacco lobby with actually writing restaurant owners and cigarette' reads in part try
the letter and duping the bar own- makers against health advocates, The ban, which covers restau- Antismoking advocates,howev-
er—and the Oakley Chamber of sparked the spouting of statistics rants in unincorporated areas in er,say the alliance has ties to to-
Commerce that approved the let- and counter-statistics and fueled Contra Costa County such as Oak- bacco interests, such as cigarette
ter—into spreading misinforma- accusations of dirty dealing from ley but not nearby Antioch,is now maker Philip Morris. They say it
Lion. both sides. opposed by the Oakley chamber is spreading erroneous informa-
"It's part of the tobacco indus- Oakley's controversial letter and many city council members. Lion in letters such as Wads-
try's strategy," said Kevin Go-e- was signed by Linda Wadsworth, the letter said. worth's.
bet, manager of legislative owner of the Buzz Inn, and writ- Antismokin ou s sav the let- "The `Haut problem is that it
programs for Americans for Non- ten on Oakley Chamber of Com- ter war, �v arart e says restaurants are losing 30 to
smokers'Rights."They come into melee letterhead. It was sent to CaWorrd_a Business_ swu-
town, provide disinformation and city council members across the rant Ail nce� which they allege is See SMOKme, back page
W, liCG�i (or / /aw v--
Helping you breathe a little easier
TOBACCO INDUSTRY FRONT GROUPS
March 16, 1993
New information is in italics. Individuals are listed at the end.
Y
THE BECK COMPANY candidates and legislation,that supports the United States
3700 Newport Boulevard,Suite 303B Constitution and the Bill of Rights." The president of the .,-
Newport Beach,California 92663 group is Doris Angus,the owner of a country club on the
(714)730-0662 outskirts of Roseville. CARL was one of the main
FAX: (714)723-0853 objectors of the Roseville ordinance. In the event of
Representatives: Gary Beck termination, remaining funds will be turned over to the
The Beck Company calls itself a public, business, and Rocky Mountain Elk Foundation. Byrne is listed on
government relations firm. Gary Beck recently attended a campaign filing statements in Sacramento as the treasurer.
tobacco control conference in Los Angeles, where he Although they told the city of Roseville in July that they
admitted that he worked with both the California Business were a new local group,they filed as lobbying group with
and Restaurant Alliance and the California Restaurant the Secretary of State on February 25, 1991.
Association.
CALIFORNIA BUSINESS & RESTAURANT
CAL-STOP ALLIANCE
1225-8th Street,Suite 350 Representatives: Fred Karger,Peter Gambee,Tracy
Sacramento,California 95814 Scott,Tracy Sand born,Kathy Gatharum,Chris Ducra, --
(916)448-3585 Auralee Street
Representatives: Paige Gruemmer 2265 Westwood Boulevard#481
This group,whose Sacramento and San Diego off ces are Los Angeles, California 90064
identical to addresses for the Tobacco Institute, has (310)474.7919
called cities, including Pasadena, about tobacco control Southern California-based group active in opposing ordi-
activities. The organization has fought San Diego's nances throughout California, including Walnut Creek,
proposed smoking controlordinance,although ilteyrefuse Contra Costa County, San Diego and Oakland. Karger
to identify,theirfitnding sources. They work closely with initially began to gather information in Walnut Creek
the San Diego Tavern and Restaurant Association,pay- under RSVP's name before coming up with a new name.
ing the consultant fee for Nikki Clay, a public relations CBRA was founded by the Dolphin Media Group, a
consultant hired to represent SDTRA on a task force public relations firm which lists Philip Morris as one of its
convened by the City of San Diego to negotiate the major clients. Karger is the Executive Vice President of
provisions of a pending sntokefree ordinance. the Dolphin Media Group. Until recently, CBRA was
located on the sameflooras the Dolphin Group,and they
CALIFORNIANS AGAINST RESTRICTIVE LEG- shared a fax number. When their relationship became
ISLATION (C.A.R.L.) too obvious a connection, CBRA moved its offices, and
Representatives: Doris Angus,Lydon Byrne the Dolphin Media Group now claims to have never
2644 Garfield Avenue heard of CBRA. Before obvious ties were severed.
Carmichael,California 95608 secretaries transfered telephone calls from one group to
(916)486-3704 the other. The Dolphin Group picks up the tab for many
According to statements filed in Sacramento in February, of CBRA's expenses. For example, when Tracy Scott
the organization's purpose is to "oppose and support testified in Marin County on CBRA's behalf. her hotel
® Recycled paper
2530 San Pablo Avenue, Suite J• Berkeley, California 94702 * (510) 841-3032 / FAX (510) 841-7702
reservations were made under the Dolphin Group's name. smokefree restaurant ordinances. The letter encouraged
Although Kargerclaimslocal restaurant owners asked councilmembers in other cities to oppose a similar ordi-
for his help, local businesses claim that he approached nance. Although the letter indicated no connection to
them offering to provide any necessary help to oppose CBRA,the women who signed it later admitted its source.
Walnut Creek's ordinance. Local businesses state that he In July of 1992, the Oakley Chamber of Commerce
has helped them for free. Karger and other representatives mailed a similar letter to every locally elected official in
initially refused to reveal the source of his income. How- California. The letter falsely claimed that smokefree
ever,Tracy Scotthas repeatedly adnutted that at least 20% restaurant ordinances in Contra Costa County werea
of their revenues come from the tobacco industry. Al- disaster. The letters were postmarked in Baton Rouge,
though she said that the rest of their funds come from Louisiana,and the author,Linda Wadsworth,later admit-
restaurants,many restaurants that have attended meetings ted that she simply signed a letter written by CBRA.
set up by CBRA say that they have never been asked to A similar letter appeared in September of 1992,when
make a contribution. Karger now admits that CBRA newly-elected Bellflower Councilmembers Ruth Gilson r
receives funding from the tobacco industry. and Ken Cleveland sent a letter to almost every locally-
Karger and Gambee formerly denied any connection elected official in the state. The letter stated that the
to RSVP, but CBRA receptionists are willing to take Bellflower ordinance had hurt restaurant sales—even
telephone messages for Rudy Cole,and Karger privately though both councilmembers had conceded that there was
admitted that Cole suggested that he set up CBRA. In no evidence of economic hardshipwhen they repealedtheir
addition,Cole recently presented a report which he claimed ordinance. Ruth Gilson adm]ttedto reporters that the letter "
RSVP had prepared. The report was written by Peter was written and mailed by CBRA. -
Gambee of CBRA,indicating that the distinction between Gary Beck of the Beck Company recently admitted
CBRA and RSVP is merely cosmetic. This report, that he works with both the CBRA and the California
alleging loss of business to restaurants in Bellflower,has Restaurant Association,which previously denied any con-
beencirculated throughout the state with anewcoversheet nection to CBRA.
implying that the study was commissioned at the request
of the Mayor of Bellfower. In fact, the Mayor and the CALIFORNIANS FOR FAIR BUSINESS POLICY
Council conducted their own study which found no loss of Representatives: Bradley Hertz,Daralyn E.Reed
business. The Daralyn Reed Company
Kathy Gatharum,who works in Los Angeles,claimed 1441 Fourth Street
to have an extensive"network"of"informants"through- Santa Monica,California 90401
out California.These are likely individuals who call Philip (213)319-0412
Moms or RJ Reynolds' "Smokers' Hotlines"and whose Original]y Sacramentans for Fair Business Policy(SFBP),
information is passed on to CBRA. She claimed that the this group changed its name and became a statewide group
city clerk had sent her a notice about a proposed ordinance on February 25, 1991. Their filing statements explicitly
in Madera,but the clerk denies sending anyone a notice. indicate that they are "sponsored by Tobacco Manufac-
The organization has an enormous travel budget; turers,Wholesalers and Restaurants."
Karger and Gambee, both from Los Angeles, are in As Sacramentans for a Fair Business Policy, the
Northern California regularly, and Gatharum offered to group fought the Sacramento City and County ordinances
fly within 24 hours to a small town in Central California, and spent more than$300,000 in tobacco money to gather
Their budget cannot be sustained.by the dues of the few signatures for a referendum drive. They succeeded in
restaurants who make token donations in order that the stalling he county ordinance,which was placed on the June
organization can claim to be funded by membership 1992 ballot,but failed to gather enough signatures for the
restaurants. city ordinance.
CBRA has ghostwritten several anti-ordinance let- Tim Pueyo,who was listed as President of SFBP,is a
ters, which they have sent to locally elected officials in paid consultant for the tobacco industry. In addition,the
California, including communities not even considering organization's original address on campaign filing state-
restricting smoking. In December of 1991,CBRA wrote ments was the same as the lobbying firm of Nielsen.
a letter signed by the mayor of Walnut Creek and a Merksamer, Hodgson, Parrinello& Mueller• which does "
councilmember in Martinez. Both cities are in Contra extensive work for the tobacco industry and has received
Costa County, California, and both had passed 100%r morethan$l millionfrom the industry since 1987. SFBP's
2
treasurer,Charles H.Bell,works for Nielson Merksamer. Secretary of State as a "Mutual Benefit" (rather than
Shortly after changing their name to CFBP, Bell was "Public Benefit")nonprofit. However, the federal gov-
dropped as treasurer and Daralyn E.Reed was added. The ernment apparently has no record of them as a nonprofit
Daralyn Reed Company appears to only be an intermedi- organization for tax purposes.
ary group responsible for filing campaign statements and Although the group claims to be independent of the
concealing who CFPB's true representatives are. Bradley tobacco industry, they have used the industry's mailing
Hertz, who is listed on filing statements as a political lists, and they apparently have close connections with
consultant,now represents the organization to the press. Californians for Fair Business Policy, which receives
Hertz personally coordinated the campaign against Long virtually all of its funding from the tobacco industry. For
Beach's ordinance,and either coordinated or assisted in all example,Naylane Merrell,an officer of CSR and believed
of the other referenda campaigns in California. to be the wife of Bob Merrell(the current CSR President), -
According to filing statements,the organization was received$1,500 from CFBP to collect voter signatures for
founded to"Support and/or oppose the qualification and a referendum drive.CSR is not yet registered as a lobbying
passage of referenda and initiative measures determined to group or a nonprofit in California,but it may take some
be in the best interests of the organization's policies and time for their documents to be processed. In March of
objectives—to ensure the adoption and maintenance of 1992,CSR sent a mailing to its members in Los Angeles
fair business policies by governmental agencies in Califor- trying to generate"grass roots"opposition to the proposed
nia." From 1990 through June of 1992, CFBP spent ordinance. The alerts were personalized by council dis-
$2,308,447.50 helping referenda campaigns to repeal trict. Although the organization claims to be based in
smoking control ordinances qualify for the ballot, and Sacramento, the return address on the L.A. alert was
funding opposition campaigns once they qualified. In 12226 Victory Blvd.,Suite 332,North Hollywood,91606. -
Sacramento County,CFBP spent $1,832,096.31. They CSR may have ties with TBP Political Consulting, a
spent $40,078.61 in Visalia, $87,410.54 in Long Beach group with documented ties to RJR. TBPapparentlypaid
(which was weakened the ordinance rather than placing it fora March 1993 CSR mailing in San Mateo County,CA.
before the voters),$275,182.11 in Sacramento City(which
failed to qualify), $14,910.51 in Oroville, $21,029.77 in CAPITOL RESEARCH CENTER
E1 Dorado County,$34,492.38 inParadise,and$3,247.27 Representatives: James T. Bennett
in Sebastopol. James T.Bennett,a George Mason University professor,
recently launched a vehement attack against the An►eri-
CALIFORNIANS FOR FAIR LAWS can Cancer Society and other voluntary health associa-
Representatives: Ron Bearce,Gary Kunkel tions. He was funded by the Capitol Research Center to
P.O.Box 3135 conduct the studies upon which his attacks are based.
571 Cuesta Drive CRC has always been very careful to avoid directly
San Luis Obispo, California 93405 answering whether or not they receive fiu►ding from the
(805)343-5480 tobacco industry, but Philip Morris has now been iden-
Based in San Luis Obispo, but claims to be based state- tified as a major contributor.
wide. They worked against Walnut Creek ordinance and
S.B.93 in 1991. CENTER FOR INDOOR AIR RESEARCH
Representatives: Dr.Max Eisenberg,director
CALIFORNIANS FOR SMOKERS' RIGHTS According to the director, this group receives generous
Representatives: Bob Merrell . funding from the tobacco industry. "[T]here's no ques-
P.O.Box 19022 Lion that a predonitnant portion of the budget is from
Sacramento,California 95819 tobacco-related interests,"Eisenberg hin►selfadmits. In
f CSR recently used tobacco industry mailing lists in an exchange, they produce studies that the in►dustry uses in
effort to launch a new organization with the appearance of public relations campaigns.
being a low-budget, grass roots public interest group
supporting smokers. The group requests a nominal $5 COUNCIL FOR TOBACCO RESEARCH
membership fee, ostensibly to open a Sacramento office The Council for Tobacco Research has served as the
but probably only to be able to claim that they are funded tobacco industry's research arm since 1954. Although the
by their members. The group is registered with the Council claims to be independent of the tobacco industry's
3 .
control,U.S.District Judge H.Lee Sarokin,after review- Codings on mailing labels match those used by RJR,but
ing a sampling of CTR documents,recently ruled that the return address is that ofJan Hall's house trailer in Antioch.
organization has served as a"front" and"shield" for the Hall has admitted to using RJR's toll-free number, but
tobaccoindustry againstlawsuits and Congressional hear- refused tobe interviewedby alocal newspaper,saying that
ings dealing with smoking. CTR has served to create the she was told not to say anything. ,
impression that studies proving the health hazards of
smoking and secondhand are"controversial"and"incon- HEALTHY BUILDINGS INTERNATIONAL
elusive." Representatives: Gray Robertson,Simon Turner
The Council has a secret "special projects" division This organization describes itself as impartial consultants
run by tobacco industry attorneys, which assessed re- on indoor air quality,which advises companies on how to
search in order to identify expert witnesses who would makeaircleaner.In its ten years of making inspections,the
testify on behalf of the tobacco industry at court trials and organization has never advised a company to go smoke-
" hearings. Judge Sarokin ruled that CTR's research was free. Robertson has admitted that the organization re-
"nothing but a public relations ploy—a fraud—to deflect ceives about 20%of its income from the tobacco industry,
the growing evidence against the [tobacco] industry, to but former-employee Jeff Seckler says that it is much
encourage smokers to continue and nonsmokers to begin, higher—higher than 50%. Robertson even told Seckler,
and to reassure the public that adverse information would "[M]y personal net worth has been significantly increased
be disclosed." Federal prosecutors have issued subpoenas over the past several years as a result of our involvement
for CTR's documents,and criminal fraud charges may be with the tobacco industry." Seckler says that 90% of the
forthcoming. work he did was for the Tobacco Institute. The industry ,
pays HBI to travel the country and testify before legisla-
THE DOLPHIN MEDIA GROUP tors to downplay the significance of secondhand smoke.
1225 Eighth Street,Suite 425 When Pepsi Cola headquarters went smokefree after
Sacramento,California 95814 consulting with HBI,the consultants had to prove to Philip
(916)441-4383 Morris that they recommended against a smoking ban—
FAX: (916)441-4132 indicating that the tobacco industry's influence over HBI
1047 Gayley Avenue is greater than the organization will admit. Secklerreports
- Los Angeles,California 90024 that the tobacco industry also has complete editorial
(213)208-6686 control overHBI's magazine. A Philip Morris executive
Representatives: Fred Karger, Robert Padgett once ordered an issue redone after 50,000 issues had
The Dolphin Media Group,a public relations firm which been printed because she didn't like the way an article
lists Philip Morris prominently among its clients,appears was written. One of their international spokespersons,
tobethe founderof theCalifornia Business and Restaurant Simon Turner,is the son of Clive Turner, former head of
Alliance. Karger, the Executive Vice President of the the British Tobacco Institute and current head of the
Dolphin Group, is the founder and primary lobbyist for Tobacco Institute of Hong Kong.
CBRA. Robert Padgett has telephoned cities and
organizations on behalf of the Dolphin Group. Although WALT KLEIN & ASSOCIATES
denies any connection to the tobacco industry, literature 200 Brookstown Avenue#300
from the company itself proudly and prominently lists Winston-Salem,North Carolina 27102
Philip Morris second on its list of clients. The Dolphin Representatives: Walt Klein, Kirk Sanders
Group shares a Los Angeles office and fax machine with An organization which apparently specializes in conduct-
CBRA. In addition,Cal-STOP,another organization,has ing surveys, referenda signature-gathering, and related
an office down the hall from the Dolphin Group's activities,Walt Klein & Associates has been calling city
Sacramento office,and appears to be connected to them. councils throughout California to determine when smok-
ing legislation will be on the agenda. Representatives will
FAIRNESS FOR CONTRA COSTA COUNTY sometimes leave only their names and address,or call their
Representative: Jan Hall organization WKA. They have received at least$50.000
3301 Buchanan Road #70 for Californians for Fair Business Policy, a tobacco
Antioch,California 94509 industry front group funded almost exclusively by the
Established through R.J. Reynolds' toll-free number. tobacco industry.
4
RAY MCNALLY AND ASSOCIATES RESTAURANTS FOR A SENSIBLE VOLUNTARY
Diann Rogers POLICY(RSVP)
1817 Capitol Avenue,Suite A Representatives: Rudy Cole,Erica Taylor
Sacramento,California 95814 5757 Wilshire Boulevard,8th Floor
Philip Morris,the largest tobacco company in the U.S.,is Los Angeles,California 90036
a client of Ray McNally&Associates. Diann Rogers sent RSVP was founded by Rudy Cole in 1990 to fight the Los
personalized letters on Ray McNally letterhead to direc- Angeles smokefree ordinance. Rudy Cole, who is not a
tors of all Health Departments in California requesting that restaurant owner, founded the Beverly Hills Restaurant
information on pending tobacco control ordinances be sent Association to oppose its smokefree ordinance in 1987.
to Rogers at Ray McNally and Associates, a public Barry Fogel,president of the Association during its oppo-
relations firm. She has worked with the Tahoe-Douglas sition to the ordinance, states that Cole was their liaison
Chamber of Commerce, and met with the El Dorado with the tobacco industry, which helped pay their legal
County Department of Health to offer a tobacco industry bills.
compromise smoking ordinance. At the meeting, she Cole admitted to the press that he solicited and re-
claimed to represent the Sacramento Restaurant Associa- ceived contributions from the tobacco industry,although
bon and gave their address and phone number as a place he continues to deny such funding at city council hearings.
where she could be reached. She is now working with the However,in aninterview with the Los Angeles Times,Cole
Sacramento Restaurant Merchants Association ,and has stated"We do receive support from the tobacco industry.
enlisted the help of Dr.Edward Munz of ENV Services to ..and I would like to get more money from them,not less."
do indoor air samples and analyses comparing air quality Cole repeated this admission on the Ron Reagan show on
in smoking and nonsmoking restaurants. She has met with November 15, 1991. In fact,the Tobacco Institute admits
County Supervisors,along with Patrick McWhorter of the that RSVP is cosponsoring their"It's the Law"campaign,
Tobacco Institute, to oppose local smoking ordinances. along with two tobacco vending machine associations—
The firm has been very active in opposing an smoking despite the fact that a genuine restaurant trade association
ordinance on the ballot in Paradise(Butte County),Cali- has little or no involvement in selling cigarettes over the
fornia and other areas. Linda Horton,a woman leading the counter, and therefore would have no need to become
opposition in Paradise,claims that their organization has involved with the program.
had no contact with Ray McNally &Associates,but has During the fight against the Los Angeles ordinance,
distributed information to the city council withMcNally's RSVP claimed to represent 1,000 L.A. restaurants, but
return address on it. The same information was provided only 440 restaurants were listed on their membership lists.
to the Colfax (Placer County)City Council Of those,20%said they were not a member of RSVP,and
12% said they supported a smokefree restaurant ordi-
NATIONAL ENVIRONMENTAL DEVELOPMENT nance. Many reported that they did not donate any money;
ASSOCIATIONITOTAL INDOOR ENVIRONMEN- those who did gave small contributions. RSVP hired
TAL QUALITY COALITION Manatt, Phelps, Rothenberg and Phillips, a law firm
Representatives: Sally Robertson, Ward Hubbell renowned for its high fees whose client list includes the
The National Environmental Development Association Tobacco Institute and the Beverly Hills Restaurant Asso-
last year created the Total lndoorEnvironmenta!Quality ciation. RSVP has also used the Tobacco Institute's public
Coalition, known as NEDAITIEQ. R.J. Reynolds is an relations firm Ogilvy & Mather.
original corporatefounderand member ofNEDAMEQ. In some areas, Cole claims to represent restaurants
lit thepress release announcing the organilzation'sfound- throughout the state,but in Walnut Creek and other places.
ing, the group claims that "the correlation bem-een poor he admitted represent ing only Los Angeles restaurants.
indoor environmental quality and adverse health effects Cole claims that restaurants in Beverly Hills lost 3017( to
hasn't been proven"—a common refrain of the tobacco 40%of their business under their 100%ordinance during
industry. NEDAITIEQ,like the tobacco industry,argues the two months that it was in effect,but he has never been
that more studies are needed before regulations of any able to substantiate that figure. In fact,a study conducted
indoor air con taminants(like tobaccosmoke)are consid- by the University of California at San Francisco, using
,. ered. data from the California Board of Equalization,found no „
5
loss of revenue for Beverly Hills. to defeat the ordinance after it had been placed on the
RS VPclaims to be a nonprofit,but is not registered as ballot. Californians for Fair Business Policy, which
such with the state for tax purposes. The state also has no receives 99.8% of its income from the tobacco industry,
record of RSVP as a nonprofit organization. Cole is not paid Pueyo $23,068 during the first six months of 1991
a registered lobbyist in Sacramento or Los Angeles, and alone. A July 1992 letter from RJ Reynolds indicates that
does not need to reveal his funding sources. However,he Pueyo continues to represent the tobacco industry in
has done extensive lobbying in Sacramento on state legis- organizing"smokers' rights"groups. P
lation. Although he tells cities that they will lose business In March 1993,TBPapparentlypaid fora nailing at
unless restaurant legislation is uniform throughout the CaliforniansforSmokers'Rights letterhead in San Mateo
state,he tells Sacramento legislators that the state will lose County, California.
business unless there is a uniform national law. Erica
Taylor has also identified herself over the telephone to the TDS, LIMITED
Placer County Tobacco Control Program as being with Representatives: Theodore Sterling
RSVP. TDS, Ltd., is an indoor air consultingfirm in Vancouver,
British Columbia. According to Jim Repace of the
SACRAMENTO RESTAURANT MERCHANTS Environmental Protection Agency, TDS's job "is to inf l-
ASSOCIATION trate groups like theAmerican Society ofHeating,Refrig-
Representatives: Diann Rogers,Sam Manolakas erating and Air Conditioning Engineers, which sets 1AQ
This group is not part of the Sacramento Restaurant standards, and represent the tobacco industry interests
Association, which is a local chapter of the California without appearing to."
Restaurant Association. Rogers works for Ray McNally
& Associates, a public relations firm in Sacramento. Bradley W.Hertz
Manolakas has connections with Tim Pueyo and is also 15223 Magnolia Boulevard,Suite A
involved with Sacramentans for a Fair Business Policy. Sherman Oaks,California 91403
The group is working with Dr. Edward Munz of ENV (818) 789-3322
Services to conduct indoor air quality studies comparing FAX: (818) 789-4995
smoking and nonsmoking restaurants. The organization Received$3,239.51 from Californians for Fair Business
appears to be run out of the offices of the public relations Policy(CFPB)in consulting fees. Hertz coordinated the
• firm Ray McNally&Associates,since office staff is able Long Beach referendum drive,and attended every hearing '
to transfer calls to Ray McNally&Associates,and the two but did not testify. According to Barry Fadem,an attorney
organizations share a fax number. with Bagatalos&Fadem(a San Francisco law firm which
has represented the tobacco industry for many years and
TBP POLITICAL CONSULTING which receives a great deal of money from CFBP).Hertz
Tim Pueyo is the official spokesperson for CFBP. His answering
2435 Polk Street,Suite 8 machine has a message indicating that it is for CFBP.
San Francisco,California 94109
(415)474-6295 John Hoy
(800)333-8683 3208 Cahuenga Boulevard West#162
Pueyo has admitted to the press that he works for the Los Angeles,California 90068
tobacco industry. In 1990, Pueyo was one of several (213) 874-3036
consultants who helped R.J.Reynolds organize smokers in (800) 333-8683
230 communities around the country. In Eureka and other Identified in a July 1992 letter from RJ Reynolds'as being
Northern California cities,Pueyo told smokers to call him one of three of their representatives who organize"smok-
if an ordinance was introduced so that he could help them ers' rights" groups in California. The.toll-free number
fight it. He warned them to deny that R.J. Reynolds was provided with his name is for RJR.
involved,and to tell the media that they had spontaneously
organized to protect their rights. He was listed as president Dr.Maurice Levoix
of Sacramentans for Fair Business Policy, which is now For the past two years,Dr.Levoix has repeatedly testified
Californians for Fair Business Policy, and he loaned against smoking restrictions, claiming that the studies
$1,200 to TUFF in Lodi,the organization which attempted demonstrating the health risks of passive smoking are -
6
flawed and inconclusive. In October of 1992, when memo regarding the victory of the Paradise smokefree
questioned during testimony before the California Air ballot measure.
Resources Board, Dr. Levoix finally admitted that he
received funding from the tobacco industry. Kent Rhodes
5400 Front Street
Sam Manolakes Rocklin,CA 95677
Owner of Bradshaws Restaurant in Sacramento County, 632-2525
and a leader of Sacramentans for Fair Business Policy. Providing tobacco industry ordinance identical to one
Recently has been working in El Dorado County and distributed in El Dorado County to Placer County Super-
Roseville to organize business community against proposed visor Mike Fluty. Evidently also working with Bev
smoking ordinance. He is alsoi nvolved with Diann Rogers Bedard of the North Lake Tahoe Chamber of Commerce,
and the Sacramento Restaurant Merchants Association. who wants the Tahoe area to be exempt from any smoking
ordinance. Connection to tobacco industry is obscure.
Pat McWhorter Phone number leads to"TCC"in Rocklin.
Tobacco Institute
1-800-454-3543 Robert Schuman
Met with El Dorado County Department of Health along 2307 Galveston Street
with Diann Rogers and Sam Manolakes. Probably the San Diego,California 92110
source of the tobacco industry compromise ordinance that (619)276-5808
has circulated in El Dorado and Placer Counties. He has (800)333-8683
also contacted the Amador County Health Department, Robert Schuman is identified in a letter from RJ Reynolds
and may be working in other areas in the state as well. as being one of three representatives who organize"smok-
ers'rights"groups in California. The toll-free number is
John Nelson for RJR.
2320 Hooke Way
Sacramento, CA 94822 Dave Tambling
Nelson contacted the Chino Hills City Clerk, seeking 5690 DTC Boulevard#315
information on the sponsor of a smokefree ordinance Englewood, Colorado 80111
pending in Chino Hills. Specifically,he wanted informa- Dave Tambling has called city councils throughout Cali-
tion on hercampaign expenditures. Nelson also traveled forma asking about proposed tobacco control policies. He
from Sacramento to Southern California to attend a appears to work for a research firm that represents the
Chino Hills city council meeting. The name Jolin R. tobacco industry.
Nelson,Jr.appears on an April 2, 1992 Tobacco Institute
7
�M
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1 ,
ENVIRONMENTAL TOBACCO
SMOKE
BACKGROUND
United States Office of June 1989
Environmental Protection Air and Radiation
Agency (ANR-445)
®EPA Indoor Air Facts No. 5
Environmental
Tobacco Smoke
Environmental Tobacco Smoke (ETS) is one of the Why ETS Is Harmful
most widespread and harmful indoor air pollutants.
ETS comes from secondhand smoke exhaled by Because the organic material in tobacco doesn't burn
smokers and sidestream smoke emitted from the completely,cigarette smoke contains more than 4,700
burning end of cigarettes, cigars, and pipes. ETS is chemical compounds, including: carbon monoxide,
a mixture of irritating gases and carcinogenic tar nicotine, carcinogenic tars,sulfur dioxide,ammonia,
Particles. It is a known cause of lung cancer and nitrogen oxides, vinyl chloride, hydrogen cyanide,
respiratory symptoms, and has been linked to heart formaldehyde, radionuclides, benzene, and arsenic.
disease. Breathing in ETS is also known as 'involun— These chemicals have been shown in animal studies
tary' or 'passive" smoking. to be highly toxic. Many are treated as hazardous
when emitted into outdoor air by toxic—wastc dumps
What's The Big Deal About A Little Smoke? and chemical plants.
In the United States, 50 million smokers annually There are 43 carcinogenic compounds in tobacco
smoke approximately 600 billion cigarettes, 4 billion smoke. In addition,-some substances are mutagcnic,
cigars, and the equivalent of 11 billion pipesful of which means they can cause permanent, often
tobacco. Since eo le spend a harmful, changes in the genetic material of cells.
p p p approximately 90 EPA research has shown that ETS is the major
perr,ent of their time indoors, this means that about
467,000 tons of tobacco are burned indoors each source of mutagens indoors when smoking occurs.
year. Over a 16—hour day, the average smoker Higher levels of mutagenic particles are found in
smokes about two cigarettes per hour, and takes homes with ETS than in homes with wood stoves or
about ten minutes per cigarette. Thus, it takes only in outdoor urban environments with numerous diesel
a few smokers in a given space to release a more—or— trucks and buses.
less steady stream of ETS into the indoor air. Many studies have shown that nonsmokers absorb
In 1985, three major bodies were independently ETS components in their body fluids. The effect of •�
convened to consider the public health implications ETS on nonsmokers. depends on the duration of
of passive smoking. Commissioned by the U.S, exposure. According to the National Research
Public Health Service under the Surgeon General, by Council, short—term visitors to a smoking area arc
the National Research Council (NRC) at the request most likely to be annoyed by the tobacco smoke
of EPA, and b the congressional] odors, whereas nonsmoking occupants of the area
Y g y-mandated are more likely to complain about irritating effects
Interagency Task Force on Environmental Cancer, to the eyes, nose or throat. Long—term exposure to
Heart, and Lung Disease, the three bodies arrived at ETS may lead to more serious health effects.
a consensus: passive smoking significantly increases
the risk of lung cancer in adults. In the words of the Impact On Children
Surgeon General, "a substantial number of the lung
cancer deaths that occur among nonsmokers can be Passive smoking induces serious respiratory symp-
attributed to involuntary smoking.' Moreover, there toms in children. Wheezing, coughing and sputum
was agreement that passive smoking substantially production among children of smoking parents
increases respiratory illness in children and the NRC increase by 20 percent to 80 percent depending on
recommended eliminating ETS from the environ— the symptom being assessed and the number of
merits of small children. smokers in the household. Asthmatic children are
particularly at risk.
Printed on Recycled Paper
Children of smokers have significantly higher can double the amount of particulate air pollution
rates of hospitalization for bronchitis and pneu- 'inhaled by nonsmoking members of the household.
monia, and a number of studies report that chronic
car infections are more common in young children Evidence Of Nonsmoker Exposure
whose parents smoke. Also lung development is
slower in children exposed to ETS. Lung problems Nicotine, a chemical unique to tobacco, has been
caused by ETS exposure in childhood can extend into found to'be a widespread air contaminant in build-
adult life. ings where smoking occurs. Nicotine breaks down
into cotinine as it passes through the body. Cotinine
ETS And Cancer can be detected and measured in the saliva, blood,
and urine of nonsmokers, indicating they have
The U.S. Surgeon General and the NRC agree that absorbed tobacco smoke from the air. Concentra-
ETS can cause cancer. The NRC estimates that the tions of cotinine have been found in the body fluids
risk of lung cancer is roughly 30 percent higher for of infants of smoking parents, and of adults who
nonsmoking spouses of smokers than for nonsmoking were-unaware they had been exposed to ETS.'
spouses of nonsmokers. In 1986, an estimated 23,000
U.S: nonsmokers died from lung cancer, and the Removal Of ETS From Indoor Air
Surgeon General attributes a substantial number of
those deaths to passive smoking. Environmental tobacco smoke can be totally removed
r
from the indoor air only by-removing the source
ETS And Heart Disease (cigarette smoking). Separating smokers and non-
smokers in the same room may reduce, but will not
The Interagency Task Force on Environmental eliminate, nonsmokers' exposure to tobacco smoke.
Cancer, Heart, and Lung Disease Workshop on ETS placing smokers and non-smokers in separate rooms
concluded that the effects of ETS on the heart may that are on the same ventilation system also may
be of even greater concern than its cancer-causing reduce nonsmokers' exposure to tobacco smoke; this
-,ffects on the lungs. ETS aggravates the condition approach, however, will probably not eliminate
,f people with heart disease, and several studies have exposure to tobacco smoke since most pollutants
linked involuntary smoking with heart disease. readily disperse through a common air space and
since, in public or commercial buildings, most
ETS's Contribution To Indoor Air Pollution I4VAC systems recirculate much of the contaminated
There are many potential sources of indoor air indoor air.
pollution,' including chemicals emanating from In 1981, the American Society of I{eating, Refri-
building materials, furnishings, and consumer pro- gerating, and Air-Conditioning Engineers
.ducts; gases from combustion appliances like space (ASHRAE), in its standard "Ventilation for Accept- „^
heaters and furnaces; and biological contaminants able Indoor Air Quality" recommended five cubic
from a variety of sources. Because cigarettes, pipes, feet of outside air per minute per occupant
and cigars produce clouds of tar particles when (cfm/occ) in smoke-free office buildings and 20
smoked, ETS is a major contributor of particulate cfm/occ in buildings where smoking is permitted.
indoor air pollution. ETS also contributes numerous These recommendations were not designed to reduce
toxic gases to indoor air, including carbon monoxide, health risks (for example, limiting cancer incidence
formaldehyde and ammonia. or eye irritation); rather, the recommendations were
Field studies, controlled experiments,and mathe-. intended to control the odor from tobacco smoke so
matical models show that,under typical conditions of that 80 percent of visitors (smokers and nonsmokers.
smoking and ventilation, ETS diffuses rapidly combined) to the building find it acceptable. A
throughout buildings and homes, persists for long Proposed revision of this standard recommends a
periods after smoking ends, and represents one of minimum of 15 cfm/occ in all buildings.
the strongest sources of indoor-air particulate pol- Research indicates that total removal of tobacco'
lution in buildings where smoking is permitted. smoke 'through ventilation is both technically and
Studies of indoor air quality in commercial and economically impractical. The effectiveness of air
public buildings show that particulate levels in areas filters for removing ED'S particles from the indoor
here smoking is permitted are considerably higher air is generally dependent on the type and efficiency
.Ilan in nonsmoking areas. Studies using personal air of the air cleaner used; the effectiveness of air
monitors have shown that a single smoker in a home cleaners in removing the gaseous components of
2
I
tobacco smoke and other air pollutants requires Association, Cancer Society or Heart Association, or
further rz search. the following:
Since there is no established, health-based thres-
hold for exposure to environmental tobacco smoke Office on Smoking and Health.
and since EPA generally does not recognize a no- U.S. Public Health Service
effect or safe level for cancer causing agents, the 5600 Fishers Lane, Room 1-10
Agency recommends that exposure to environmental Rockville, MD 20857
tobacco smoke be minimized wherever possible. The Public Relations Office
most effective way to minimize exposure is to American Society of Pleating
restrict smoking to smoking areas that are separately Refrigerating and Air Conditioning '
ventilated and directly exhausted to the outside, or Engineers (ASI•iRAE)
by eliminating smoking in the building entirely. 1791 Tullie Circle•, NE.
Atlanta, GA 30329
The Public Reaction To ETS
Office of Cancer Communications
People are becoming increasingly sensitized to the National Cancer Institute
issue of ETS. Numerous surveys have documented 1-800-4-CANCER
that the majority of both smokers and nonsmokers
support restrictions on smoking Smoking Policy Institute
su
pp g in public,particular- 914 East Jefferson
ly in the workplace. In a 1987 Gallup National Suite 219
Opinion Survey, 55 percent of all persons inter- P.O. Box 20271
viewed (including smokers and nonsmokers) were in Seattle, WA 98102
favor of a total ban on all smoking in public places.
As a result, thousands of businesses and hundreds fi rairlcans for Nonsmokers' RIghts
of cities, as well as over 40 states and the District of 2530 San Pablo Ave., Suite J
Columbia restrict smoking in various settings. The Berkeley, CA 94702
number continues to grow rapidly.
Action on Smoking and Health
Conclusion 2013 11 Street, NW.
EPA shares the recommendations of the 1986 Sur- Washington, DC 20006
geon General's Report: Cigarette smoke is only one of many indoor air
o Adults should protect the health of children by pollutants that can affect your health and comfort.
not exposing them to environmental tobacco Other EPA publications concerning the quality of
smoke. indoor air include:
o Employers and employees should ensure that the o The Inside Story: A Guide to Indoor Air Quality
act of smoking does not expose nonsmokers to o Directory of State Indoor Air Contacts
environmental tobacco smoke •by restricting o Indoor Air Facts #I: EPA and Indoor Air Quality
smoking to separately ventilated areas or banning o Indoor Air Facts n2: EPA Indoor Air Quality
smoking from buildings. Implementation Plan
o Smokers should ensure that their behavior does o Indoor Air Facts #3: Ventildlion and.Air Quality
not jeopardize the health of others. in Offices
o Indoor Air Facts #4: Sick Buildings
o Nonsmokers should support smokers who are
trying to quit. These publications, as well as additional copies of
this fact sheet, are available from:
For More Information Public Information Center
U.S. Environmental Protection Agency
For additional information on environmental tobacco Mail Code PM-211 B
smoke, contact your state or local health depart- 401 M Street, SW.
ments, nonprofit agencies such as your local Lung Washington, DC 20460
3
ulluu..wu w., .�ul„� ... ......„u,.... _..... ...:,uu v .u� u..0 �: ........... ............
- Environmental Protection Development Radiation December 1992
Agency Washington,DC 20460 Washington,DC 20460
14=�EPA Respiratory Health
Effects of Passive
Smoking :
Lun g Cancer and
Other Disorders
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EPA/600/6-90/006F
December 1992
ij
RESPIRATORY HEALTH EFFECTS
OF PASSIVE SMOKING:
LUNG CANCER AND OTHER DISORDERS
!.
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Major funding for this report has been provided by the Indoor Air Division,
Office of Atmospheric and Indoor Air Programs
i
Office of Health and Environmental.Assessment
Office of Research and Development
U.S. Environmental Protection Agency
Washington, D.C.
Printed on Recycled Paper
1
CONTENTS"'
Tables . . . . . . . . . . . . . . . . . . . . . . . . . .'. . . . . . . . . . . . 6 , vii
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . xii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv
Authors, Contributors, and Reviewers . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . xv
1. SUMMARY AND CONCLUSIONS . . . . . . . .. . . . . . . . . . . . . . . . 1-1
I.I. MAJOR CONCLUSIONS . . . . . . . . . . . : . .'. . . . . . . . .'. . . . . . . . . . . . . . . . . 1-I
1.2. BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-2
1.3. PRIMARY FINDINGS . . . . . . . . . . . .. . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . 1-4
1.3.1. ETS and Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-6
1.3.1.1. Hazard Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-6
1.3.1.2. Estimation of Population Risk . . . . . . . . . . . . . . . . . . . . . . . . . . 1-11
1.3.2. ETS and Noncancer Respiratory Disorders . . . . . . . . . . . . . . . . . . . . . . 1-12
2. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-1
2.1. FINDINGS OF PREVIOUS REVIEWS . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-2
2.2. DEVELOPMENT OF EPA REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-5
2.2.1. Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-5
2.2.2. Use of EPA's Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-6
2.2.3. Contents of This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2-8
3. ESTIMATION OF ENVIRONMENTAL TOBACCO SMOKE EXPOSURE . . . . . . . . . 3-1
._ 3.1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-1
3.2. PHYSICAL AND CHEMICAL PROPERTIES . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-2
3.3. ASSESSING ETS EXPOSURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-10
3.3.1. Environmental Concentrations of ETS . . . . . . . . . . . . . . . . . . . . . . . . . . 3-12
3.3.1.1. Markers for Environmental Tobacco Smoke 3-18
3.3.1.2. Measured Exposures to ETS-Associated Nicotine and RSP . . . . 3-22
33.2. Biomarkers of ETS Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-40
3.3.3. Questionnaires for Assessing ETS Exposures . . . . . . . . . . . . . . . . . . . . . . 3-48
3.4. SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-51
4. HAZARD IDENTIFICATION I: LUNG CANCER IN ACTIVE SMOKERS,
LONG-TERM ANIMAL BIOASSAYS, AND GENOTOXICITY STUDIES . . . . . . . . . 4-1
4.1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-1
4.2. LUNG CANCER IN ACTIVE SMOKERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-2
4.2.1. Time Trends . . . . . . . . . . . . . . . . 4-2
4.2.2. Dose-Response Relationships . . . . . . . . 4-5
4.2.3. Histological Types of Lung Cancer and Associations With Smoking . . . . . 4-10
4.2.4. Proportion of Risk Attributable to Active Smoking . . . . . . . . . . . . . . . . . 4-23
iii
i
CONTENTS (continued)
4.3. LIFETIME ANIMAL STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-23
4.3.1. Inhalation Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-25
4.3.2. Intrapulmonary Implantations of Cigarette Smoke Condensates • • • • • . . . 4-25 4-26
4.3.3. Mouse Skin Painting of Cigarette Smoke Condensates . . . . . . . . . . . . . . . 4-27
4.4. GENOTOXICITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4-27
4.5. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. HAZARD IDENTIFICATION II: INTERPRETATION OF EPIDEMIOLOGIC
STt1DIES ON ENVIRONMENTAL TOBACCO SMOKE AND LUNG CANCER . . . . 5-1
5.1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-1
5.2. RELATIVE RISKS USED IN STATISTICAL INFERENCE . . . . . . . . . . . . . . . . 5-15
5.2.1. Selection of Relative Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-15
5.2.2. Downward Adjustment to Relative Risk for Smoker
Misclassification Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-22
5.3. STATISTICAL INFERENCE . . 5-25
5.3.1. Introduction . . . . . . . . . . . . . . . . . 5-25
5.3.2. Analysis of Data by Study and Country . . . . . . . . . . . . . . . . . . . . . . . . . .
5.3.2.1. Tests for Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-31
5.3.2.2. Confidence Intervals • • • • • • • • • • • • • • • • • . . . . 5-34
5-36
5.3.3 Analysis of Data by Exposure Level . . . . . . . . . . . . . . . . . . . . • • • • • . . . . -36
5.3.3.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • • • • . . . . S 5-37
5.3.3.2. Analysis of High-Exposure Data . . . . . . . . . . . . . . . . . . . . . . . .
5.3.3.3. Tests for Trend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-40
5.3.4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-51
5.4. STUDY RESULTS ON FACTORS THAT MAY AFFECT
LUNG CANCER RISK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-48
5.4.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-48
5.4.2. History of Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-51
5.4.3. Family History of Lung Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-53
5.4.4. Heat Sources for Cooking or Heating . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-53
5.4.5. Cooking With Oil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-54 ,s
5-54
5.4.6. Occupation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-55
5.4.7. Dietary Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-60
5.4.8. Summary on Potential Modifying Factors . . . . . . . . . . . . . . . .
' S.S. ANALYSIS BY TIER AND COUNTRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-60
5.6. CONCLUSIONS FOR HAZARD IDENTIFICATION . . . . . . . . . . . . . . . . . . . . . 5-63
5-63
5.6.1. Criteria for Causality . . . . . . . . . . . . . . . . . . . . . . . . . . . • 5-67
5.6.2. Assessment of Causality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • • • • . . . .
5-68
5.6.3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. POPULATION RISK OF LUNG CANCER FROM PASSIVE SMOKING . . . . . . . . . . 6-1
6.1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-1
6.2. PRIOR APPROACHES TO ESTIMATION OF POPULATION RISK . . . . . . . . . 6-1
6.2.1. Examples Using Epidemiologic Data 6-2
6.2.2. Examples Based on Cigarette-Equivalents 6-5 {
t-
iv
}
CONTENTS (continued)
6.3. THIS REPORT'S ESTIMATES OF LUNG CANCER MORTALITY
ATTRIBUTABLE TO ETS IN THE UNITED STATES . . . . . .. . . . . . . . . . . . 6-8
6.3.1. Introduction and Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-8
6.3.2. Parameters and Formulae for Attributable Risk . . . . . . . . . . . . . . . . . . 6-10
6.3.3. U.S. Lung Cancer Mortality Estimates Based on Results of
Combined Estimates from I U.S. Studies . . . . . . . . . . . . . . . . . . . . . . . . 6-16
6.3.3.1. U.S. Lung Cancer Mortality Estimates for Female
Never-Smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-17
6.3.3.2. U.S. Lung Cancer Mortality Estimates for Male
Never-Smokers . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . 6-17
6.3.3.3. U.S. Lung Cancer Mortality Estimates for'Long-Term
(5+ Years) Former Smokers . . . ... . . . . . . . . . . . . . . . . . . . . . . . 6-20
6.3.4. U.S. Lung Cancer Mortality Estimates Based on Results of the
Fontham et al. (1991) Study (FONT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-21
6.3.5. Sensitivity to Parameter Values . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-27
6.4. SUMMARY AND CONCLUSIONS ON POPULATION RISK . . . . . . . . . . . . . . 6-29
7. PASSIVE SMOKING AND RESPIRATORY DISORDERS
OTHER THAN CANCER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-1
7.2. BIOLOGICAL MECHANISMS . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
7.2.1. Plausibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-2
7.2.2. Effects of Exposure In Utero and During the.First
Months of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-3
7.2.3. Long-Term Significance of Early Effects on
Airway Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-6
7.2.4. Exposure to ETS and Bronchial Hyperresponsiveness . . . . . . . . . . . . . . . . 7-7
7.2.5. ETS Exposure and Atopy .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-9
7.3. EFFECT OF PASSIVE SMOKING ON ACUTE RESPIRATORY
ILLNESSES IN CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-10
7.3.1. Recent Studies on Acute Lower Respiratory Illnesses . . . . . . . . . . . . . . . . 7-'11
7.3.2. Summary and Discussion of Acute Respiratory Illnesses . . . . . . . . . . . . 7-20
7.4. PASSIVE SMOKING'AND ACUTE AND CHRONIC
MIDDLE EAR DISEASES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-21
7.4.1. Recent Studies on Acute and Chronic Middle Ear Diseases . . . . . . . . . . . . 7-22
7.4.2. Summary and Discussion of Middle Ear Diseases . . . . . . . . . . . . . . . . . . . 7-28
7.5. EFFECT OF PASSIVE SMOKING ON COUGH, PHLEGM,
AND WHEEZING 7-30
7.5.1. Recent Studies on the Effect of Passive Smoking on Cough,
Phlegm, and Wheezing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-30
7.5.2. Summary and Discussion on Cough, Phlegm, and
Wheezing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-41
7.6. EFFECT OF PASSIVE SMOKING ON ASTHMA . . . . . . . . . . . . . . . . . . . . . . . . 7-43
7.6.1. Recent Studies on the Effect of Passive Smoking on
Asthma in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-44
7.6.2. Summary and Discussion on Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7-50
7.7. ETS EXPOSURE AND SUDDEN INFANT DEATH SYNDROME . . . . . . . . . . . 7-51
f v
N '
�1 '
i
.j
i 3
I
CONTENTS (continued) '
` 7-57
7,8. PASSIVE SMOKING AND LUNG FUNCTION IN CHILDREN . . . . . . . . . .
7.8.1. Recent Studies on Passive Smoking and Lung Function 7-57
in Children . . . . Function
7.8.2.. Summary and Discussion on pulmonary 7-63
in Children. - . . . . . . . . . . . . . . .
7.9. PASSIVE SMOKING AND RESPIRATORY SYMPTOMS AND 7-64
LUNG FUNCTION IN ADULTS . . . . . . . . . . . . . . . . . . . . . . . . . M
7.93. Recent Studies on Passive Smoking and Adult Respiratory 7-64
. . . . . . . . . . . . . . . . .
Symptoms and Lung Function • 'Respiratory Symptoms and --
7.9.2. Summary and Discussion on Resp Y Y 7-68
Lung Function in Adults . . . . . . . . . . . . . . . . .
8. ASSESSMENT OF INCREASED RISK FOR RESPIRATORY ILLNESSES IN 8-1
CHILDREN FROM ENVIRONMENTAL TOBACCO SMOKE . . . . . . . . . . .. . . . .
. . . . . '8-1
8.1. POSSIBLE ROLE OF CONFOUNDING • • 8-2
8.2. MISCLASSIFICATION OF EXPOSED AND.UNEXPOSED SUBJECTS 8-2
8.2.1. Effect of Active Smoking in Children . . . . . . . . ; 8-3
8.2.2. Misreporting and Background Exposure . . . . 8-5
8.3. ADJUSTMENT FOR BACKGROUND EXPOSURE .
8.4. ASSESSMENT OF RISK . . . . . . . . . . . 8-10
8.4.1. Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-13
Lower Respiratory Illness 8-15 '
8.4.2. Syndrome . . . . . . . . . . . . . . . . . . . .
8.4.3. Sudden Infant Death Sy , , , , , . . 8-15
8.5. CONCLUSIONS . . . . . . . . . . . . . • • • • • • ' ' . . . ADD-1
ADDENDUM: PERTINENT NEW STUDIES `
APPENDIX A: REVIEWS AND TIER ASSIGNMENTS FOR EPIDEMIOLOGIC A-I
STUDIES OF ETS AND LUNG CANCER . . . • • • • • • • • • • ' ' ' ' '
METHOD FOR CORRECTING RELATIVE RISK FOR
APPENDIX B: M , , , , , . . . . B-1
SMOKER MISCLASSIFICATION . . . . . . .
. . . . . . . . . .
PPENDIX C: LUNG CANCER MORTALITY RATES ATTRIBUTABLE TO
A C-1
SPOUSAL ETS IN INDIVIDUAL EPIDEMIOLOGIC STUDIES . . . .
APPENDIX
• , D-1
D: STATISTICAL FORMULAE . . . . . . . . . . . . . . . . . • . .
R-1 •
SELECTED BIBLIOGRAPHY . . . . . . • • • • • • • • • . • ' ' ' ' ' ' • • . • • • • • ,
vi
I �
i
is
1. SUMMARY AND CONCLUSIONS
1.1. MAJOR CONCLUSIONS
Based on the weight of the available scientific.evidence, the U.S. Environmental
Protection Agency (EPA) has concluded that the widespread exposure to environmental
tobacco smoke (ETS) in the United States presents a serious and substantial public health
c impact.
In adults:
• ETS is a human lung carcinogen, responsible for approximately 3,000 lung a
cancer deaths annually in U.S. nonsmokers.
In children: {
4 • ETS exposure is causally associated with an increased risk of lower
respiratory tract infections (LRIs) such as bronchitis and pneumonia. This
,
E
report estimates that 150,000 to 300,000 cases annually in infants and young a
t
children up to 18 months of age are attributable to ETS.
• ETS exposure is causally associated with increased prevalence of fluid in the
middle ear, symptoms of upper respiratory tract irritation, and a small but
significant reduction in lung function.
• ETS exposure is causally associated with additional episodes and increased t
i severity of symptoms in children with asthma. This report estimates that
200,000 to 1,000,000 asthmatic children have their condition worsened by
exposure to ETS.
• ETS exposure is a risk factor for new cases of asthma in children who have
not previously displayed symptoms.
CURRENT INTELLIGENCE BULLETIN 54
ENVIRONMENTAL TOBACCO SMOKE
IN THE WORKPLACE
Lung Cancer and Other Health Effects
U.S. Department of Health and Human Services
Public Health Service
Centers for Disease Control
National Institute for Occupational Safety and Health
Division of Standards Development and Technology Transfer
Division of Surveillance, Hazard Evaluations, and Field Studies
June 1991
FOREWORD
Current Intelligence Bulletins (CIBs)are issued by the National Institute for Occupational
Safety and Health (NIOSH),Centers for Disease Control,Atlanta, Georgia,to disseminate
new scientific information about occupational hazards. A CIB may draw attention to a
formerly unrecognized hazard, report new data on a known hazard, or disseminate infor-
mation on hazard control.
CIBs are distributed to representatives of academia,industry,organized labor,public health
agencies,and public interest groups,as well as to Federal agencies responsible for ensuring
the safety and health of workers.
1
Copies are available to individuals upon request from the Division of Standards Develop-
ment and Technology Transfer, NIOSH (Robert A. Taft Laboratories, 4676 Columbia
Parkway,Cincinnati,Ohio 45226). We welcome suggestions concerning the content,style,
and distribution of these documents.
i
The purpose of this bulletin is to disseminate information about the potential risk of cancer
to workers exposed to environmental tobacco smoke(ETS). In 1964,the Surgeon General
issued the first report on smoking and health,which concluded that cigarette smoking causes
lung cancer. Since then,research on the toxicity and carcinogenicity of tobacco smoke has
demonstrated that the health risk from inhaling tobacco smoke is not limited to the smoker,
but also includes those who inhale ETS. ETS contains many of the toxic agents and
carcinogens that are present in mainstream smoke, but in diluted form. Recent
epidemiologic studies support and reinforce earlier published reviews by the Surgeon
General and the National Research Council demonstrating that exposure to ETS can cause
lung cancer. These reviews estimated the relative risk of lung cancer to be approximately
1.3 for a nonsmoker living with a smoker compared with a nonsmoker living with a
nonsmoker. In addition, recent evidence also suggests a possible association between
exposure to ETS and an increased risk of heart disease in nonsmokers. Although these data
were not gathered in an occupational setting, ETS meets the criteria of the Occupational
Safety and Health Administration (OSHA) for classification as a potential occupational
carcinogen [Title 29 of the Code of Federal Regulations, Part 1990]. NIOSH therefore
considers ETS to be a potential occupational carcinogen and recommends that exposures
be reduced to the lowest feasible concentration. All available preventive measures should
be used to minimize occupational exposure to ETS.
i �
NIOSH urges employers to disseminate this information to employees. NIOSH also
requests that professional and trade associations and unions inform their members about
the potential hazards of exposure to ETS. Readers seeking more detailed information about
the studies cited in this bulletin are urged to consult the original publications.
WJ�. ald Millar,M.D., D.T.P.H. (Loud.)
Assistant Surgeon General
Director,National Institute for
Occupational Safety and Health
Centers for Disease Control
iv
d
ABSTRACT
The National Institute for Occupational Safety and Health (NIOSH) has determined that
environmental tobacco smoke(ETS)is potentially carcinogenic to occupationally exposed
workers. In 1964,the Surgeon General issued the first report on smoking and health,which
concluded that cigarette smoke causes lung cancer. Since then,research on the toxicity and
carcinogenicity of tobacco smoke has demonstrated that the health risk from inhaling
tobacco smoke is not limited to the smoker, but also includes those who inhale ETS. ETS
contains many of the toxic agents and carcinogens that are present in mainstream smoke,
but in diluted form. Recent epidemiologic studies support and reinforce earlier published
reviews by the Surgeon General and the National Research Council demonstrating that
exposure to ETS can cause lung cancer. These reviews estimated the relative risk of lung
cancer to be approximately 1.3 for a nonsmoker living with a smoker compared with a
nonsmoker living with a nonsmoker. In addition, recent evidence suggests a possible
association between exposure of nonsmokers to ETS and an increased risk of heart disease.
Although these data were not gathered in an occupational setting,ETS meets the criteria of
the Occupational Safety and Health Administration (OSHA) for classifying substances as
potential occupational carcinogens[Title 29 of the Code of Federal Regulations,Part 1990].
NIOSH therefore recommends that ETS be regarded as a potential occupational carcinogen
in conformance with the OSHA carcinogen policy, and that exposures to ETS be reduced
to the lowest feasible concentration. Employers should minimize occupational exposure
to ETS by using all available preventive measures.
V
CONTENTS
Foreword . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . iii
Abstract . . . . . . . . . . . . . . . .
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Reports of the Surgeon General on the Health Effects of Tobacco Smoke . . . . . . 1
Comparison of the Chemical Composition of ETS and MS . . . . . . . . . . . . . 2
Potential for Occupational Exposure . . . . . . . . . . . . . . . . . . . . . . . . . 2
Epidemiologic Studies of Nonsmokers Exposed to ETS . . . . . . . . . . . . . . . 4
Lung Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Surgeon General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
NRC [1986] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Wald et al. [1986] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Blot and Fraumeni [198 6] . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Hole et al. [1989] . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . 5
Brownson et al. [1987] . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Humble et al. [1987] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Gao et al. [1987] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Lam et al. [1987] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Janerich et al. [1990] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Shimizu et al. [1988] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Geng et al. [1988] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Summary of Results from Lung Cancer Studies . . . . . . . . . . . . . . . 8
Heart Disease . . . . . . . . . . . . . . . . . . . . 9
Surgeon General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
NRC [1986] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Other Epidemiologic and Experimental Studies . . . . . . . . . . . . . . . 9
Summary of Results from Heart Disease Studies . . . . . . . . . . . . . 11
Other Adverse Health Effects . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Methods for Controlling Involuntary Exposure to ETS . . . . . . . . . . . . . . 12
Eliminating Tobacco Use from the Workplace . . . . . . . . . . . . . . . . . 13
Isolating Smokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Research Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Appendix. Positions of Other Agencies Regarding ETS . . . . . . . . . . . . . . . . 18
vii
CURRENT INTELLIGENCE B ULLE TIN 54
ENVIRONMENTAL TOBACCO SMOKE IN THE WORKPLACE
Lung Cancer and Other Health Effects
INTRODUCTION • Results from recent epidemiologic studies of
nonsmokers exposed to ETS
Tie Surgeon General has concluded that tobacco
smoke is a carcinogen and an important risk factor Methods for controlling involuntary exposures to
for heart disease. The purpose of this bulletin is to ETS in the workplace are also discussed.
disseminate information about the potential car-
cinogenicity of environmental tobacco smoke*
(ETS) in the workplace. Evidence is now clear REPORTS OF THE SURGEON GENERAL
that the health risk from inhaling tobacco smoke is ON THE HEALTH EFFECTS OF TOBACCO
not limited to the smoker, but also includes those SMOKE
who inhale ETS. Recent epidemiologic studies of
nonsmokers exposed to ETS have shown an in- 1964,the Surgeon General issued the first report
creased relative risk for lung cancer compared with on smoking and health, which concluded that
unexposed nonsmokers. In addition, recent cigarette smoke causes cancer [DREW 1964]:
evidence suggests that exposure of nonsmokers to
ETS may be associated with an increased risk of Cigarette smoking is causally related to lung
heart disease. This bulletin describes the results cancer in men; the magnitude of the effect of
and implications of these studies. cigarette smoking far outweighs all other fac-
tors. The data for women,though less exten-
The conclusions and recommendations in this Cur- sive, point in the same direction. . . . The risk
rent Intelligence Bulletin (CIB) are based on the of developing lung cancer increases with
followin g: duration of smoking and the number of
cigarettes smoked per day,and is diminished
• Reports of the Surgeon General on the health by discontinuing smoking.
effects of tobacco smoke
Since 1964,evidence has continued to support the
• Comparison of the chemical composition of causal relationship between exposure to cigarette
ETS with that of mainstream smokef (MS) smoke and lung cancer, demonstrating that risk
increases with amount and duration of smoking.
'Tobacco smoke in the ambient atmosphere composed of Subsequent research has increased our knowledge
sidestream smoke and exhaled mainstream smoke. See about the toxicity and carcinogenicity of tobacco
page viii for a complete list of defuzitions and abbreviations.
sup-
Smoke drawn through the tobacco and into the smoker's smoke and the risks of exposure. Additional mouth. port for the Surgeon General's conclusion has
June 1991 1
NIOSH CIB 54 Environmental Tobacco Smoke
come from (1) animal studies that demonstrated A major reason that undiluted SS and MS have
the carcinogenicity of tobacco smoke condensate, different concentrations of toxic and carcinogenic
and (2) analytical studies demonstrating that agents is that peak temperatures in the burning
tobacco smoke contains carcinogens [DHEW cone of a cigarette reach 800° to 900°C during
1972; DHHS 1982]. Cigarette smoking is the puffing, but only 600°C between puffs, resulting
major cause of lung cancer (87% of lung cancer in less complete combustion of tobacco during
deaths) and is estimated to account for 30% of all generation of SS. In addition,most of the burning
cancer deaths [DHHS 1989]. cone is oxygen deficient during smoldering and
produces a strongly reducing environment [NRC
The 1964 Surgeon General's report also pointed 1986]. Table 1 lists 26 toxic and carcinogenic
out that male cigarette smokers have higher death agents identified in SS and MS.
rates from heart disease than nonsmokers. Sub-
sequent reports have concluded that cigarette ETS is diluted in the air before it is inhaled and
smoking is a major cause of heart disease and that thus is less concentrated than MS. However, ac-
smoking is a major independent risk factor for tive inhalation of MS is limited to the time it takes
heart attack [DHEW 1968; DHHS 1983]. to smoke each cigarette,whereas exposure to ETS
is constant over the period spent in the ETS-polluted
On July 1, 1965, Congress approved the Federal environment. This fact is reflected in measure-
Cigarette Labeling and Advertising Act of 1965 ments of nicotine uptake by smokers and ETS-
(Public Law 89-92). This law,which became effec- exposed nonsmokers [DHHS 19891.
tive on January 1, 1966,was the first of a continuing
series of Federal statutes enacting warning labels to
inform the public about the health hazards of smok- POTENTIAL FOR OCCUPATIONAL
ing and, subsequently, the use of other tobacco EXPOSURE
products. Presently, the Comprehensive Smoking
Education Act(Public Law 98-474)[Title 15,§ 1331 Approximately 29% of the U.S. adult population
of the U.S. Code] requires cigarette companies to smokes cigarettes, and exposure to ETS is com-
rotate four health warnings on all cigarette packages mon [DHHS 19891. Many people who report no
and in advertisements. exposure to ETS have low concentrations of
cotinine (a metabolite of nicotine) in their urine,
COMPARISON OF THE CHEMICAL indicating exposure. The average concentration of
COMPOSITION OF ETS AND MS cotinine in the urine of nonsmokers has been
reported to be approximately 8 ng/ml compared
ETS contains many of the toxic agents and car- with approximately 1,200 ng/ml in smokers
cinogens that are present in MS,but in diluted form [Cummings et al. 1990]. The National Research
[DHHS 1986]. The major source of ETS is Council (NRC) estimated that nonsmokers ex-
sidestream smoke" (SS), which contains higher pad to ETS averaged 25 ng of urinary codnine/ml,
amounts of some toxic and carcinogenic agents and active smokers averaged 1,825 ng/ml [NRC
than MS when it is obtained in its undiluted form 1986]. Husgafvel-Pursiainen et al. [1987] found
under laboratory conditions [DHHS 1989]. For that nonsmoking restaurant workers had an
example, the release of volatile N-nitrosamines average urinary cotinine concentration of
and aromatic amines is higher in SS than in MS. 56 ng/ml,and nonsmokers not exposed to ETS had
an average concentration of 8.3 ng/ml. Other
*Smoke generated by(1)smoldering tobacco between puffs, investigators have shown that nonsmokers
and (2) smoke diffusing through the cigarette paper and living with smokers have approximately two to
escaping from the burning cone during puffing. three times the amount of urinary cotinine as
2 June 1991
Environmental Tobacco Smoke NIOSH CIB 54
Table 1.-Toxic and carcinogenic agents in undiluted cigarette SS*'t
Type of Amount in SS
Compound toxicity (per cigarette) Ratio of SS/MS
Vapor phase:
Carbon monoxide T 26.8-61 mg 2.5-14.9
Carbonyl sulfide T 2-3 mg 0.03-0.13
Benzene C 400-500µg 8-10
Formaldehyde C 1,500µg 50
3-Vinylpyridine Sc 300-450 pg 24-34
Hydrogen cyanide T 14-110µg 0.06-0.4
Hydrazine C 90 ng 3
Nitrogen oxides(NOx) T 500-2,000 pg 3.7-12.8
N-nitrosodimethylamine C 200-1,040 ng 20-130
N-nitrosopyrrolidine C 30-390 ng 6-120
Particulate phase:
Tar C 14-30 mg 1.1-15.7
Nicotine T 2.1-46 mg 1.3-21
Phenol TP 70-250 pg 1.3-3.0
Catechol CoC 58-290µg 0.67-12.8
o-Toluidine
C 3µg 18.?
2-Naphthylamine C 70 ng 39
4-A -dnobiphenyl C 140 ng 31
Benz(a)anthracene C 40-200 ng 2-4
Benzo(a)pyrene C 40-70 ng 2.5-20
Quinoline C 15-20µg 8-11
N'-nitrosonomicotine C 0.15-1.7 pg 0.5-5.0
NNK C 0.2-1.4µg 1.0-22
N-nitrosodiethanolamine C 43 ng 1.2
Cadmium C 0.72 pg 7.2
Nickel C 0.2-2.5µg 13-30
Polonium-210 C 0.5-1.6 pCi 1.06-3.7
Sources: DHHS [1989];Hoffmann and Hecht[1989].
?Abbreviations: C,carcinogenic;CoC,cocarcinogenic;MS,mainstream smoke;SC,suspected carcinogen; SS,
sidestream smoke;T,toxic;TP,tumor promoter;NNK,4-(methyl-nitrosamino)-(3-pyridyl)-1-butanone.
June 1991 3
NIOSH CIB 54 Environmental Tobacco Smoke
nonsmokers living with nonsmokers [Haley et al. risk of lung cancer among nonsmoking women,
1989]. usually wives exposed to their husbands' ETS.
The 1986 Surgeon General's report concluded that
Exposures to ETS were measured by respirable involuntary smoking is a cause of disease(includ-
suspended particulates (_<2.5 µm) and averaged ing lung cancer)in healthy nonsmokers;however,
242 µg/m3 in public access buildings [First 1984; more data on the dose and distribution of ETS
NRC 1986; Repace and Lowrey 1980, 1982]. exposure in the population are needed to accurate-
Studies reviewed by Repace and Lowrey [1990] ly estimate the magnitude of risk in the U.S.
suggested a 62% probability of exposure to ETS population [DHHS 1986].
for a nonsmoker in the workplace. However, the
relative contribution of work versus home en- NRC[1986]
vironments in ETS exposure has not been well
quantified. In addition,social settings outside the The NRC also reviewed the important epidemi-
workplace or the home(e.g.,restaurants and bowl- ologic data available in 1986(3 cohort studies and
ing alleys) may contribute significantly to ETS 10 case-control studies) on the adverse health ef-
exposure. fects of ETS exposure. These studies were the
same ones reviewed by the Surgeon General, ex-
On the basis of urinary cotinine concentrations,the cept for one case-control study. The statistical
NRC [1986] concluded that nonsmokers exposed power of a single study is often small,but it can be
to ETS absorb the equivalent of 0.1 to 1.0 cigarette improved by analyzing all the data simultaneously
per day. On the basis of 1985 data, NIOSH es- across all studies (meta-analysis). Using this ap-
timates that each cigarette smoker in the United proach,the NRC estimated that the relative risk for
States smokes an average of about 21 cigarettes per nonsmokers married to smokers was 1.25 com-
day [NCHS 1988]. Blood and urine samples pared with nonsmokers married to nonsmokers,
analyzed for vapor phase nicotine indicate that taking into account the possible misclassification
nonsmokers exposed to ETS absorb about 1% of of smokers as nonsmokers. Using data from uri-
the tobacco combustion products absorbed by ac- nary cotinine tests to estimate the extent of ETS
tive smokers [NRC 1986; DHHS 1986]. exposure,the NRC also estimated that the relative
risk of lung cancer for nonsmokers exposed to ETS
EPIDEMIOLOGIC STUDIES OF at home,at work,or elsewhere was 1.42 compared
NONSMOKERS EXPOSED TO ETS with unexposed nonsmokers, with a plausible
range of 1.24 to 1.61. The NRC concluded that
Lung Cancer "the weight of the evidence derived from epidemi-
ologic studies shows an association between ETS
Surgeon General exposure of nonsmokers and lung cancer that,
taken as a whole, is unlikely to be due to chance
The Surgeon General first addressed the possible or systematic bias."
health effects of involuntary smoking in 1972
[DHEW 1972]. Evidence associating adverse Wald et al.11986]
health effects with ETS exposure continued to be
reported, and in 1986, the Surgeon General's In another quantitative meta-analysis covering the
report entitled The Health Consequences of In- same studies reviewed by the NRC, Wald et al.
voluntary Smoking focused entirely on this subject [1986] reached similar conclusions. Their
[DHHS 1986]. Thk report cited 3 cohort studies analysis showed a 30% greater risk of lung can-
and 10 case-control studies that together docu- cer (relative risk 1.30) for nonsmokers living
mented an approximately 1.3-fold increase in the with smokers relative to nonsmokers living with
4 June 1991
Environmental Tobacco Smoke NIOSH CIB 54
nonsmokers. The authors concluded that this group was composed of persons who had smoked '
result was unlikely to have occurred by chance and during some period in the past. In the followup
that it underestimated the true risk associated with study [Hole et al. 1989], only 2 deaths from lung
exposure to ETS because nonsmokers living with cancer occurred in the unexposed group and 7 in
nonsmokers are exposed to ETS in other settings the exposed group, compared with 147 deaths
(e.g., at work). The relative risk is thus based on from lung cancer among smokers. The adjusted
a reference group that is partially exposed. relative risk for the exposed group was 2.41 (95%
CI, 0.45-12.83), compared with a relative risk of
Blot and Fraumeni[1986] 10.64 for persons who had smoked in the past. The
risk for smokers was the same whether or not they
Blot and Fraumeni [1986] analyzed the same were exposed to ETS.
studies reviewed by the Surgeon General and the
NRC except for one case-control study. Combin- Brownson et al. [1987]
ing data across the reviewed studies, these inves-
tigators concluded that the overall relative risk for Brownson et al. [1987] conducted a case-control
nonsmoking women married to husbands who study of persons diagnosed with adenocarcinoma
smoked was 1.3 (95% confidence interval [CI], of the lung. A subset of 19 nonsmoking women
1.1.-1.5)compared with nonsmoking women mar- was identified from this group and was compared
ried to nonsmokers. These authors also concluded with 47 controls. Exposure to ETS was classified
that the relative risk for nonsmokers exposed to as less than 4 hr/day or more than 4 hr/day (there
heavy smoking was 1.7 (95% CI, 1.4-2.1). They was no specification of when this exposure oc-
found that the epidemiologic studies strongly sug- curred). The odds ratio for those exposed more
gested an increased risk that was biologically than 4 hr/day was 1.68 (95% CI, 0.39-2.97) after
plausible, but that limitations in assessing ETS adjustment for confounders, whereas the odds
exposure had introduced uncertainty. ratio for those exposed fewer than 4 hr/day was
1.00. The study does not state whether the non-
Eight additional studies of lung cancer and ETS smoking females had ever smoked, but the im-
exposure among those who never smoked have plication is that they had never smoked. Because
been published since the reviews by the Surgeon many of the subjects were deceased, smoking
General [DHHS 1986; NRC 1986; Wald et al. status was often determined from interviews with
1986; Blot and Fraumeni 1986] (Table 2). next of kin. The study lacked sufficient sample
size to draw substantive conclusions, but it did
suggest an increased risk for adenocarcinoma
Hole et a/. [1989] among nonsmokers exposed to ETS.
Hole et al. [1989] updated an earlier cohort study
[Gillis et al. 1984] of 3,960 men and 4,037 women Humble at al. [1987]
in Scotland. These men and women had lived in
the same households and had been followed for an Humble et al. [1987] evaluated the risk of lung
average of 11.5 years. They were aged 45-64 at cancer in a case-control study of 28 lung cancer
the time of the original interviews, which took patients who never smoked and lived with a smok-
place from 1972 to 1976. The unexposed group ing spouse compared with a control group of 54
was defined as persons who never smoked and persons who never smoked and lived with a non-
lived with nonsmokers at the time of interview. smoking spouse. Surrogate responses about
The exposed group was composed of persons who smoking habits were used for 19 of the 28 cases,
never smoked and lived with smokers. A third with most of these data provided by the spouse.
June 1991 5
NIOSH CIB 54 Environmental Tobacco Smoke
Table 2.—Recent studies of lung cancer among ETS-cxposed persons who never smoked
Study Design Exposure definition Relative risk* Comment
Update of Gillis 12-yr followup, Living with smoker 2.41 (CI,0.45-12.83; Adjusted for age,sex,
et al. [1984] 3,960 men and or ex-smoker at 7 observed) and social class
by Hole et al. 4,037 women the time of the
[1989] aged 45-64 in survey
1972-76
Brownson et al. 19 cases, Exposure for 1.68(CI,0.39-2.97) Adjusted for age,
[1987] 47 controls 24 hr/day income,and
occupation
Humble et al. 28 cases, Lived with a spouse For cigarette ETS Adjusted for ethnicity
[1987] 54 controls who smoked exposure: and age
2.2(90% CI,
1.0-4.9)
For any type of ETS
exposure:
2.6(90% Cl,
1.2-5.6)
Gao et al. 246 cases, Lived with a smoker <20 yr, 1.0; Adjusted for age and
[1987] 375 controls 20-29 yr, education
1.1 (Cl,0.7-1.8);
30-39 yr,
1.3(Cl,0.8-2.1);
240 yr,
1.7(CI, 1.0-2.9)
Lam et al. 199 cases, Lived with a spouse 1.65(CI, 1.16-2.35) Matched for age and
[1987] 335 controls who smoked neighborhood
Janerich et al. 191 cases, 225 smoker-yr of 2.07(CI, 1.16-3.68) Matched for age,sex,
[1990] 191 controls exposure during and county of
childhood residence;relative
risk for spousal
smoking-0.9
Shimizu et al. 90 cases, Lived with mother 4.0(P<0.05) Matched for age,sex,
[1988] 163 controls who smoked and hospital;rela-
Lived with father-in-law 3.2(P<0.05) five risk for spousal
who smoked smoking- 1.1
Geng et al. 54 cases, Lived with spouse 2.16(CI, 1.03-4.53) Matched for race,age,
[1988] 93 controls who smoked sex,and marital
status;positive dose
response;method-
ologic details not
presented
*Confidence interval is 95% unless otherwise indicateu.
6 June 1991
Environmental Tobacco Smoke NIOSH CIB 54
The adjusted odds ratio for nonsmokers living with cinoma (odds ratio 2.12). These odds ratios were
a spouse who smoked cigarettes was 2.2 (90% CI, not adjusted for any confounders.
1.04.9), and it was 2.6 (90% Cl, 1.2-5.6) for
nonsmokers exposed to any type of ETS (includ-
ing pipes and cigars). There was no trend of Janerich et al.[1990]
increasing risk with increased duration of ex-
posure or increased amount regularly smoked by Janerich et al. [1990] conducted a population-
the spouse. In addition, marriage to a smoker did based case-control study of 191 persons who never
not increase the risk for persons who had ever smoked and were diagnosed with lung cancer from
smoked. This study contained no data on exposure 1982 to 1984; this group was compared with in-
to ETS outside the home or from other persons dividually matched controls who never smoked.
(nonspouses) living in the home. Controls were matched by age,sex,and county of
residence. Surrogate interviews were necessary
for 62 cases and thus were also conducted for their
Gao et al. (1987] matched controls. The number of years of ex-
posure to ETS in the home was calculated by
Gao et al. [1987] studied 672 female lung cancer summing the number of smokers in the home per
patients and 735 population-based controls in year across all years of life. The number of years
Shanghai, China. Patients had been diagnosed as exposed to ETS outside the home was also es-
having lung cancer between 1984 and 1986, and timated, although details were not given in the
both patients and controls were all interviewed report. Childhood and adolescent exposures in the
directly. The odds ratio (adjusted for age and home, adult exposures in the home, and adult
education) was 0.9 (95% CI, 0.6-1.4) for persons exposures outside the home all contributed about
who had ever lived with a smoker during adult-
hood,and 1.1 (95% CI,0.7-1.7)for those who had wally to total lifetime exposure to ETS. For
spouses, ETS exposure was also calculated by
ever lived with a smoker during childhood. How- multiplying the number of packs smoked per day
ever, for 246 married patients and 375 marred by the number of years the spouse smoked. The
controls, risk increased with increasing years of major finding of the study was a trend of increasing
marriage to a spouse who smoked, reaching lung cancer risk with increasing years of exposure
1.7 (95% CI, 1.0-2.9) among nonsmokers who during childhood. Household exposure to ETS for
lived with a smoker for more than 40 years. 25 or more years that included childhood doubled
the risk of lung cancer (odds ratio, 2.07; 95
Larry et al. [1987] CI, 1.16-3.68). No consistent increase in cancer
risk occurred with increasing years of adulthood
Lam et al. [1987] studied 445 female lung cancer exposure to all sources of ETS, but persons ex-
patients in Hong Kong matched by age with 445 posed for the greatest number of years showed the
female controls from the same neighborhood. highest risk(odds ratio, 1.11;95% CI,0.56-2.20).
Analyses (unmatched) for exposure to ETS in- Separate analyses of exposure to ETS from spousal
clud.ed 199 married patients and 335 marred con- smoking found no excess risk of lung cancer for
trols who never smoked. A small number of individuals married to smokers, and no trend of
persons who were not married and never smoked increased risk with increased years of exposure or
(5% to 6% of the patients and controls) were also with increased amount smoked by the spouse.
included and treated as unexposed to ETS. Wives Odds ratios in this study were not adjusted for any
exposed to ETS from a husband who smoked had confounders, and odds ratios for exposure to ETS
an odds ratio of 1.65 (95% CI, 1.16-2.35), with from spousal smoking do not appear to have been
the predominant type of cancer being adenocar- adjusted for childhood ETS exposures.
June 1991 7
NIOSH CIB 54 Environmental Tobacco Smoke
Shimizu et al.11988] during adulthood [Hole et al. 1989; Brownson et
al. 1987;Humble et al. 1987;Gao et al. 1987;Lam
Shimizu et al. [1988] published a case-control et al. 1987; Janerich et al. 1990; Shimizu et al.
study of 90 female lung cancer patients who never 1988; Geng et al. 1988], although some studies
smoked. Each patient was matched by age,hospi- include data on childhood exposures [Janerich et
tal, and admission date to 2 controls of the same al. 1990; Shimizu et al. 1988; Gao et al. 1987].
sex who did not have lung cancer(for 17 patients, The data from these more recent studies do not
only 1 control was used). Information was individually demonstrate a clear causal relation-
gathered about occupation,exposure to ETS,diet, ship between ETS exposure and lung cancer, but
and cooking fuels. The risk of lung cancer was their consistent finding of a relative risk greater
significantly elevated for women who never than 1.0 for nonsmokers exposed to ETS provides
smoked and lived in a home where the mother evidence of a positive association. These data are
smoked(relative risk,4.0; P<0.05) or the paternal consistent with and reinforce the reviews by NRC
grandfather smoked (relative risk, 3.2; P<0.05). [19861,DHHS [19861,Blot and Fraumeni [1986],
Exposure to the ETS of other household members and Wald et al. [1986],all of which concluded that
(including the husband, the father, and the ETS exposure is associated with an increased risk
children) was not associated with increased risk. of lung cancer for nonsmokers.
The relative risk for exposure to ETS at work was
1.2. The authors found no increasing trend in risk The most important limitation observed in all
with the number of cigarettes smoked by the studies reporting lung cancer risks among persons
mother or the paternal grandfather. However, the who never smoked is the lack of quantitative ETS
authors indicated that the subjects had trouble exposure data. Most studies have defined ex-
recalling the amount of smoking to which they had posure to ETS for nonsmokers on the basis of
been exposed. The authors also pointed out that living with or being married to a smoker. All of
in Japan, children spend considerable time with the case-control studies ascertained the potential
their mother in the home, and less with the father; for exposure by interviewing subjects and controls
it is also common for the retired father of the (or surrogates) without any other independent as-
husband to live in his son's home. sessment of ETS exposure. Questionnaires often
failed to include specific questions about all sources
Geng et al. [1988] of ETS. Most studies included limited or no infor-
mation about the risk of lung cancer from ETS
Geng et al. [1988] studied 54 nonsmoking (un- exposure in the workplace.
defined) women with lung cancer in Tianjin,
China. These patients were matched with controls The potential exists for a positive bias,particularly
by race, age, sex, and marital status. The authors in the case-control studies,where ex-smokers with
reported a significantly elevated odds ratio for the lung cancer might have been misclassified as never
patients exposed to ETS from spouses (odds ratio, having smoked. The misclassified ex-smokers are
2.16; 95% CI, 1.03-4.53), but it is not clear more likely to be married to smokers and to
whether these women included former smokers. develop lung cancer than those who never smoked.
Their risk increased with the amount and duration However,the NRC[1986]estimated that the effect
(years) of the husband's smoking. of such misclassification would have been rela-
tively slight and could not entirely account for the
Summary of Results from Lung Cancer Studies increased risk of lung cancer following exposure
to ETS. This conclusion by the NRC is based on
The studies published since 1986 have concen- calculations that assume a degree of misclassifica-
trated on ETS exposure through spousal smoking tion (based on nonsmoker urinary cotinine data)
8 June 1991
Environmental Tobacco Smoke NIOSH ClB 54
and its likely effect on the observed lung cancer specific types of cardiovascular disease associated
risk. In addition, the risk of lung cancer in these with this exposure are needed before an effect of
studies is based on a reference group of non- involuntary smoking on the etiology of cardiovas-
smokers living with nonsmokers who are exposed cular disease can be established."
to ETS in other settings. This background ex-
posure results in underestimation of the true risk. NRC[1986]
Several risk assessments have been performed for The NRC [1986] reviewed four epidemiologic
persons who never smoked and were exposed to studies that evaluated the association between
ETS. The NRC [1986] estimated that of the heart disease and ETS exposure [Garland et al.
7,000 lung cancer deaths reported in 1985 among 1985;Gillis et al. 1984;Hirayama 1984;Svendsen
'U.S.women who never smoked,2,010(29%)were et al. 1985, 1987*] (Table 3). The same NRC
attributable to ETS. The corresponding number review examined studies of the effects of ETS
for men was 820 (16%) of the 5,200 lung cancer exposure on heart rate and blood pressure among
deaths among U.S. males who never smoked. healthy individuals. No statistically significant
Wells [1988] estimated that approximately 3,000 increases were found in heart disease or effects
of the lung cancer deaths reported in 1985 among on heart rate and blood pressure. The NRC report
persons who never smoked occurred as a result of concluded that "with respect to chronic cardiovas-
ETS exposure. Repace and Lowrey [1990] es- cular morbidity and mortality, although biologi-
timated that approximately 5,000 of the lung can- cally plausible,there is no evidence of statistically
cer deaths reported in 1988 among persons who significant effects due to ETS exposure,apart from
never smoked and ex-smokers occurred as a result the study by Hirayama [see Table 3] in Japan."
of ETS exposure. These risk assessments used a
1.3 to 1.5 relative risk of lung cancer for non- Other Epidemiologic and Experimental Studies
smokers exposed to ETS at home or elsewhere
compared with unexposed persons. The number Since publication of the reports by the NRC and
of deaths attributable to ETS exposure was derived the Surgeon General, researchers have published
using standard formulas for attributable risks two epidemiologic studies of heart disease and
[Kleinbaum et al. 1983]with the estimated number ETS exposure [Humble et al. 1990; Helsing et al.
of annual lung cancer deaths in the United States 1988], and one update [Hole et al. 1989] of an
for persons who have never smoked. earlier cohort study [Gillis et al. 1984] (Table 3).
Experimental studies of the effects of ETS on the
Heart Disease heart have also been published [Davis et al. 1989;
Allred et al. 1989; Sheps et al. 1990].
Surgeon General
The studies reported by Hole et al. [1989],Helsing
The Surgeon General [DHHS 1986] reviewed et al. [1988], and Humble et al. [1990] associated
four epidemiologic studies of cardiovascular ETS exposure with an increase of heart disease
disease in persons exposed to ETS [Lee et al. 1986; among persons who never smoked. The studies by
Hirayama 1984; Gillis et al. 1984; Garland et al. Hole et al. [1989]and Helsing et al. [1988]are both
1985] (Table 3). He concluded that "further large follow-up cohort studies that used direct inter-
studies on the relationship between involuntary views of men and women who lived in the same
smoking and cardiovascular disease are needed in household. Study of these cohorts demonstrated
order to determine whether involuntary smoking
increases the risk of cardiovascular disease. More *Svendsen et al. [1985] is the abstract of the full report
detailed characterizations of exposure to ETS and published in 1987 [Svendsen et al. 1987].
June 1991 q
NIOSH CIB 54 Environmental Tobacco Smoke
Table 3.—Recent studies of heart disease among ETS-exposed persons who never smoked
Study Design Exposure definition Relative risk Comment
Update of Gillis 12-yr followup, Living with smoker 2.01 (CI, 1.21-3.35; Adjusted for cardiovas-
et al. [1984] 3,960 men and or ex-smoker in 485 observed) cular risk factors,§
by Hole et al. 4,037 women early 1970s positive dose response
[1989]' aged 45-64 in
1972-76
Humble et al. 20-yr followup, Living with smoker 1.59(CI,0.99-2.57) Adjusted for cardiovas-
[1990] 513 women in 1960 cular risk factors,dose
aged 40+ response in some strata
Helsing et al. 12-yr followup, Living with smoker Men: 1.31 Adjusted for education,
[1988] 4,162 men and or ex-smoker in (Cl, 1.1-1.6;492 positive dose response
14,873 women, 1963 observed) among women only
aged 25+in Women: 1.24
1963 (Cl, 1.1-1.4; 1,539
observed)
Svendsen et al. 7-yr average Married to smoker 1.61 (CI,0.96-2.71; Adjusted for cardiovas-
[1985, 1987] followup, 1,245 or ex-smoker 90 observed) cular risk factors,
men aged 35-57 positive dose response
in 1973-82
Garland et al. 10-yr followup, Married to smoker 2.9(estimate; Adjusted for age
[1985] 695 women or ex-smoker 19 observed)
aged 50-79 in
1972-74
Hirayama 16-yr followup, Married to smoker Low exposure: Significant dose response
[1984] 91,540 women or ex-smoker 1.10(90% CI,
aged 40+ 0.91-1.33)
High exposure:
1.31 (90% Cl,
1.06-1.93;494
observed)
Lee et al. 48 cases, 182 Married to smoker Men: 1.24' No apparent dose response
[1986] controls or ex-smoker Women: 0.93
Confidence interval is 95% unless otherwise indicated.
'Hole et al. [1989]provide updated results of the same population studied by Gillis et al. [1984].
§Serum cholesterol,blood pressure,and body mass index.
*Svendsen et al. [1987]is the full report of the abstract published by Svendsen et al. [1985].
10 June 1991
Environmental Tobacco Smoke NIOSH CIB 54
an excess of heart disease in persons who lived heart disease in the nonsmoking spouse; they con-
with smokers and never smoked compared with cluded that exposure to ETS can cause heart dis-
persons who lived with nonsmokers and never ease.
smoked. Furthermore, Hole et al. [1989] and
Humble et al. [1990] show an increasing risk for Summary of Results from Heart Disease Studies
heart disease mortality with increasing exposure to
ETS at home. Helsing et al. [1988]found a similar The principal limitation found in the lung cancer
trend in women but not men. studies also applies to the studies of heart disease
in persons exposed to ETS—that is, the indirect
Experimental studies support the hypothesis that method of assessing exposure to ETS (usually
:ETS exposure has deleterious effects on platelets defined as spousal smoking). The second limita-
and the endothelium [Davis et al. 1989] and can tion of these heart disease studies is the difficulty
decrease the time to onset of angina pectoris in in controlling for all known cardiovascular risk
patients with coronary artery disease [Allred et al. factors (e.g., blood pressure, serum cholesterol,
1989]. Allred et al. [1989] reported that the time and body mass index). In addition,the risk of heart
to angina decreased in heart disease patients who disease for ETS-exposed persons who never
exercised after exposure to airborne carbon smoked seems large compared with the risk of
monoxide (CO) at concentrations producing 2% heart disease for smokers. Unlike lung cancer
and 3.9% carboxyhemoglobin (COHb) in the mortality,where the relative risk for smokers com-
blood. Sheps et al. [1990] observed that arrhyth- pared with nonsmokers is 22.4 for men and 11.9
mias in heart disease patients increased when they for women, the relative risk of heart disease mor-
exercised after exposure to airborne CO at con- tality for smokers compared with nonsmokers is
centrations producing 6% COHb in the blood. 1.9 for men and 1.8 for women [DHHS 1989].
Persons exposed to ETS in unventilated areas have Note that the nonsmoking comparison group for
been shown to have COHb concentrations of 2% these risk estimates includes those exposed to
to 3% [NRC 1986]. ETS.
Wells[1988]estimated that among nonsmokers in Other Adverse Health Effects
the United States,32,000 deaths from heart disease
each year were attributable to ETS exposure. Several additional adverse health effects have
Wells used estimated rates for death from heart been associated with ETS exposure, including
disease among nonsmokers and a relative risk of cervical cancer [Slattery et al. 1989], ischemic
1.30 for ETS-exposed nonsmokers compared with stroke [Donnan et al. 1989],spontaneous abortion
unexposed nonsmokers. [Ahlborg 1990],and low birthweight[NRC 1986].
However, evidence is insufficient to draw con-
Glantz and Parmley [1991] recently reviewed the clusions about the relationship of ETS exposure to
epidemiologic literature on exposure to ETS and these health effects.
heart disease (including the studies in Table 3)
from 1984 to the present. These researchers es- CONCLUSIONS
timated a 30% increase (relative risk, 1.30; 95%
CI, 1.2-1.4) in the risk of death from ischemic In 1964 the Surgeon General concluded that
heart disease or myocardial infarction in nonsmok- cigarette smoke causes lung cancer. Since that
big individuals exposed to ETS at home. Glantz time, additional research on the toxicity and car-
and Parmley also noted that several of these studies cinogenicity of tobacco smoke has demonstrated
found a dose-response relation between the that the health risks from inhaling tobacco smoke
amount of smoking by the spouse and the risk of are not limited to smokers, but also include those
June 1991 11
NIOSH CIB 54 Environmental Tobacco Smoke
who inhale ETS. ETS contains many of the toxic tional Carcinogens [29 CFR 1990],also known as
agents and carcinogens found in MS,but in diluted the OSHA carcinogen policy)the most appropriate
form. Recent epidemiologic studies support and for use in identifying occupational carcinogens.
reinforce the conclusions of the reviews by the The Surgeon General has concluded that cigarette
Surgeon General and the NRC demonstrating that smoke causes lung cancer as well as heart disease.
exposure to ETS can cause lung cancer. These Table 1 lists 21 known or suspected carcinogens,
reviews estimated the relative risk for lung cancer cocarcinogens, and tumor promoters identified as
to be approximately 1.3 for nonsmokers living components of ETS and MS in analytical studies.
with smokers compared with nonsmokers living Furthermore, a large body of evidence indicates
with nonsmokers. In addition, recent evidence that exposure to ETS has produced lung cancer in
also suggests a possible association between ex- nonsmokers. NIOSH therefore considers ETS to
posure to ETS and an increased risk for heart be a potential occupational carcinogen in confor-
disease in nonsmokers. The recent epidemiologic mance with the OSHA carcinogen policy [29 CFR
studies (including those associating ETS with 19901.
other adverse health effects) point to a pattern of
health effects that is similar for both smokers and The risk of developing cancer should be decreased
nonsmokers exposed to ETS. by minimizing exposure to ETS. Employers
should therefore assess conditions that may result
NIOSH recognizes that these recent epidemiologic in worker exposure to ETS and take steps to reduce
studies have several shortcomings: lack of objec- exposures to the lowest feasible concentration.
tive measures for characterizing and quantifying
exposures, failure to adjust for all confounding METHODS FOR CONTROLLING
variables, potential misclassification of ex- INVOLUNTARY EXPOSURE TO ETS
smokers as nonsmokers, unavailability of com-
parison groups that have not been exposed to ETS, Workers should not be involuntarily exposed to
and low statistical power. Nonetheless, NIOSH tobacco smoke. To prevent worker exposures
has determined that the collective weight of to any hazardous substance, employers should
evidence (i.e., that from the Surgeon General's first eliminate hazardous workplace emissions
reports, the similarities in composition of MS and at their source. If elimination is not possible,
ETS,and the recent epidemiologic studies) is suf- emissions should be removed from the pathway
ficient to conclude that ETS poses an increased between the source and the worker[NIOSH 1983].
risk of lung cancer and possibly heart disease to Therefore, the best method for controlling
occupationally exposed workers. The epidemi- worker exposure to ETS is to eliminate tobacco use
ologic data are not sufficient to draw conclusions from the workplace and to implement a smoking
about other health effects such as cervical cancer, cessation program. Until tobacco use can be
ischemic stroke, spontaneous abortion, and low
birthweight.
*"'Potential occupational carcinogen'means any substance,
RECOMMENDATIONS or combination or mixture of substances, which causes an
increased incidence of benign and/or malignant neoplasms,
or a substantial decrease in the latency period between ex-
Several systems exist for classifying a substance posure and onset of neoplasms in humans or in one or more
as a carcinogen. Such classification systems have experimental mammalian species as the result of any oral,
been developed by NTP[1989],IARC[1987],and respiratory or dermal exposure,or any other exposure which
OSHA 29 CFR 1990 . NIOSH id the results in the induction of tumors at a site other than the site
OSHA [29 considers of administration. This definition also includes any sub-
OSHA classification system (Identification, Clas- stance which is metabolized into one or more potential
sification, and Regulation of Potential Occupa- occupational carcinogens by mammals"[29 CFR 1990.103].
12 June 1991
Environmental Tobacco Smoke NIOSH CIB 54
completely eliminated, employers should protect where smoking is permitted, ETS can spread
nonsmokers from ETS by isolating smokers. throughout the airspace of all workers. The most
Methods for eliminating tobacco use from the direct and effective method of eliminating ETS
workplace and isolating smokers are described from the workplace is to prohibit smoking in the
here briefly. workplace. Until that is achieved, employers can
designate separate, enclosed areas for smoking,
with separate ventilation. Air from this area
Eliminating Tobacco Use from the should be exhausted directly outside and not recir-
culated within the building or mixed with the
Worker exposure to ETS is most efficiently and
general dilution ventilation for the building. Ven-
tilation of the smoking area should meet general
completely controlled by simply eliminating ventilation standards,and the smoking area should
tobacco use from the workplace. To facilitate have slight negative pressure to ensure airflow into
elimination of tobacco use, employers should hi n- area rather than back into the airspace of the
plement smoking cessation programs. The As- workplace [ASHRAE 1989]. Guidance for
sociation of Schools of Public Health (ASPH)has designing local exhaust ventilation systems can be
recommended the following strategy for smoking found in Recommended Industrial Ventilation
cessation [NIOSH 1986]. Specifically, manage- Guidelines [Hagopian and Bastress 1976], In-
ment and labor should work together to develop dustrial Ventilation—A Manual of Recommended
appropriate nonsmoking policies that include practice [ACGIH 1986], and Fundamentals
some or all of the following: Governing the Design and Operation of Local
• Prohibit smoking at the workplace and provide Exhaust Systems [ANSI 1979].
sufficient disincentives for those who do not warning signs should be posted at the entrances to
comply the workplace in both English and the predominant
• Distribute information about health promotion language of non-English-reading workers. These
and the harmful effects of smoking signs should state that smoking is prohibited or
permitted only in designated smoking areas. If
• Offer smoking-cessation classes to all workers designated smoking areas are provided, they
• Establish incentives to encourage workers to should be clearly identified by signs.
stop smoking
RESEARCH NEEDS
Further information regarding workplace smoking
policies and smoking cessation programs can be Research is needed to investigate the following
found in No Smoking: A Decision Maker's Guide moues:
to Reducing Smoking at the Worksite [American
Cancer Society et al. 1985]. • More accurate quantification of the increased
risk of lung cancer associated with ETS ex-
Isolating Smokers
posure, including determination of other con-
tributing factors(e.g.,occupational exposures)
The 1986 Surgeon General's report on involuntary that may accentuate the risk
smoking concluded that,"the simple separation of • Determination of the concentration and dis-
smokers and nonsmokers within the same airspace tribution of ETS components in the workplace
may reduce, but does not eliminate, the exposure to help quantify the risk for the U.S. working
of nonsmokers to ETS." In indoor workplaces population
June 1991 13
NIOSH CIB 54 Environmental Tobacco Smoke
• The association of ETS exposure with cancer ANSI [1979]. American national standard—
other than lung cancer fundamentals governing the design and operation
• The relationship between ETS exposure and of local exhaust systems. New York, NY:
cardiovascular disease American National Standards Institute,Inc.,ANSI
Z9.2-1979.
• The relationship between ETS exposure and
nonmalignant respiratory diseases such as ASHRAE [1989]. Ventilation for acceptable in-
asthma, bronchitis, and emphysema, and the door air quality. Atlanta, GA: American Society
effects of ETS on lung function and respiratory of Heating, Refrigerating, and Air-Conditioning
symptoms Engineers, Inc., ASHRAE 62-1989.
• Possible mechanisms of ETS damage to the
cardiovascular system, such as increased Blot WJ,Fraumeni JF Jr. [1986]. Passive smoking
platelet aggregation, increased COHb leading and lung cancer. ]NCI 77(5):993-1000.
to oxygen deprivation, or damage to the en- Brownson RC, Reif JS, Keefe TJ, Ferguson SW,
dothelium Pritzl JA[1987]. Risk factors for adenocarcinoma
• Effects of workplace smoking restrictions on of the lung. Am J Epidemiol 125(1):25-34.
the ETS exposure of nonsmokers and ETS-
related health effects in nonsmokers 29 CFR 1990. Code of Federal regulations.
Washington, DC: U.S. Government Printing Of-
fice, Office of the Federal Register.
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June 1991 17
NIOSH CIB 54 Environmental Tobacco Smoke
APPENDIX
POSITIONS OF OTHER AGENCIES REGARDING ETS
The Occupational Safety and Health Administra- The International Agency for Research on Can-
tion (OSHA) and the Mine Safety and Health cer [IARC 1986] stated that epidemiologic
Administration(MSHA)have not established per- studies have demonstrated an increased risk of
missible exposure limits (PELs) for ETS in the lung cancer for nonsmoking spouses of
workplace. OSHA is now preparing to address smokers. Although researchers had substantial
this issue as part of an indoor air quality standard. difficulty in determining exposure to ETS and
other risk factors for the cancers studied, IARC
The U.S.Environmental Protection Agency(EPA) concluded that "passive smoking gives rise to
states that ETS is a known cause of lung cancer some risk of cancer." IARC also concluded
and respiratory symptoms and that it has been that "there is sufficient evidence that tobacco
linked to heart disease. EPA also recommends that smoke is carcinogenic to humans," and that
exposure to ETS be minimized wherever possible "there is sufficient evidence that inhalation of
by restricting smoking to separately ventilated tobacco smoke as well as topical application of
areas directly exhausted to the outside,or by entirely tobacco smoke condensate cause cancer in ex-
eliminating smoking in buildings [EPA 1989]. perimental animals."
18 June 1991
*U.S.GOVERNMENT PRINTING OFFICE: 1991/548-235/40013