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DISCLAIMER
THIS DOCUMENT IS A PRELIMINARY DRAFT AND SUBJECT TO CHANGE.
IT HAS NOT BEEN RELEASED BY THE U.S. ENVIRONMENTAL PROTECTION
AGENCY AND SHOULD NOT BE CONSTRUED TO REPRESENT AGENCY
POLICY.
MENTION OF TRADE OR COMPANY NAMES DOES NOT CONSTITUTE
APPROVAL OR ENDORSEMENT.
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NOTE TO REVIEWERS
This draft document is part of EPA's overall effort to characterize indoor air
pollution problems and develop strategies for reducing the public's exposure to indoor air
contaminants. It is also part of an EPA initiative to address one of the most prevalent and
harmful indoor air pollutants: environmental tobacco smoke (ETS). The National Cancer
Institute has collaborated in the development of this draft document.
EPA is transmitting this document to its Science Advisory Board (SAB) for comment
along with a formal risk assessment of ETS entitled "Health Effects of Passive Smoking:
Assessment of Lung Cancer in Adults and Respiratory Disorders in Children"
(EPA/600/6-90/006A). The risk assessment seeks to classify ETS according to EPA's
carcinogen risk assessment guidelines, to estimate the excess lung cancer deaths attributable
to ETS exposure, and to assess the association between passive smoking and respiratory
effects. The risk assessment and this document will be the subject of an SAB review
meeting. Persons interested in providing comments may obtain a copy of the draft risk
assessment by contacting:
ORD Publications Office, CERI-FRN
U.S. Environmental Protection Agency
26 West Martin Luther King Drive
Cincinnati, Ohio 45268
(513)569-7562; FTS 684-7562
A formal Notice of Availability appears in the Federal Register.
This document is intended to provide government and private sector decision
makers with information on the technical basis for controlling involuntary nonsmoker
exposure to environmental tobacco smoke and to describe a variety of technical and policy
options for instituting effective smoking restrictions. The draft policy guide includes some
information from the as-yet-unfinalized risk assessment.
BOTH DOCUMENTS ARE REVIEW DRAFTS - PLEASE DO NOT CITE OR QUOTE.
BECAUSE INFORMATION CONTAINED IN BOTH THE POLICY GUIDE AND THE RISK
ASSESSMENT IS UNDERGOING REVIEW AND IS SUBJECT TO CHANGE, THESE
DOCUMENTS DO NOT REPRESENT AGENCY POLICY.
Please review this draft for technical accuracy, completeness, and effectiveness in
communicating with a predominantly non-technical audience. Comments MUST BE IN
WRITING, POSTMARKED NO LATER THAN AUGUST 31,1990, and should be mailed
to:
ETS COMMENTS
Indoor Air Division (ANR-445)
EPA, 401 M Street, SW
Washington, DC 20460
FAX #: (202) 382-7991
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Table of Contents
Acknowledgements
Introduction 1
Key Points 3
Recommendations 5
Part I - ENVIRONMENTAL TOBACCO SMOKE: THE PROBLEM 6
Chapter 1 - What is ETS? 7
Chapter 2 - Measuring ETS in the Air and Body 11
Chapter 3 - Health Effects of ETS 15
Chapter 4 - How Big is the Risk from ETS? 19
Part II - ENVIRONMENTAL TOBACCO SMOKE: THE SOLUTIONS. 21
Chapter 5 - Reducing Exposure to ETS 22
Chapter 6 - Regulating Smoking and ETS 26
Chapter 7 - Developing Effective Smoking Policies 33
Chapter 8 - Cost Savings Related to ETS Reduction 37
Chapter 9 - Public Attitudes Towards ETS 41
Part III - CASE STUDIES 42
Chapter 10 - Smoking Policies in the Private Workplace 43
Chapter 11 - Smoking Policies in Government Facilities 50
Chapter 12 - Smoking Policies in Health Care Facilities 55
Chapter 13 - Smoking Policies in Schools 60
Resources 63
Footnotes 65
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Acknowledgments
This publication was prepared by the Indoor Air Division of the Office of Air and Radiation,
United Stales Environmental Protection Agency, Washington, D.C. It was developed in
collaboration with the Smoking, Tobacco, and Cancer Program of the National Cancer
Institute, National Institutes of Health, Department of Health and Human Services,
Washington, D.C.
The publication was written by Robert Rosner and Robin Simons of the Smoking Policy
Institute, Seattle, Washington. Information for Chapter 9, Developing Effective Smoking
Policies, was drawn from "90 Days To A Smoke Free Workplace," Copyright © 1987,
Smoking Policy Institute.
The authors acknowledge with gratitude all of the individuals and organizations who
provided support and assistance during the development of the report. Special thanks to
Robert Axelrad and Jim Repace of the Environmental Protection Agency; Donald Shopland
of the National Cancer Institute; C. Everett Koop, Former Surgeon General; Thomas
Novotny of the Office of Smoking and Health; William Cain and Brian Leaderer of Yale
University; Jonathan Samet of the University of New Mexico; John Spengler of Harvard
University; and Jennifer Stock, Bill Weis and Tim Lowenberg of the Smoking Policy
Institute. For assistance in developing the case studies the authors wish to thank Len Beil
of U.S. West Communications and Sue Pisha of the Communications Workers of America;
Caren Olsen, Bill Heim and Lynn Warne of Honeywell; Lee Fairbanks of the U.S. Indian
Health Service; Howard Slrickler of the City of Bellevue; Martha Riddell of the Lexington
Clinic; Ray Zoellick of Swedish Hospital; and Dennis Underwood of the Andover Public
Schools.
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Introduction
There are many potential sources of indoor air pollution, including chemicals emanating
from building materials, furnishings, and consumer products; gases from combustion
appliances like space heaters and furnaces; and biological contaminants from a variety of
sources. However, field studies, controlled experiments and mathematical models have
shown that Environmental Tobacco Smoke (ETS) is one of the most widespread and
harmful indoor air pollutants and is a major contributor to particulate indoor air pollution.
The smoke emitted by cigarettes, cigars and pipes contains over 4,000 chemicals, many of
which are known carcinogens and toxins. These are inhaled by smokers during the process
of smoking, and by nonsmokers who breathe the ETS emitted into the air. The breathing of
ETS by nonsmokers is called "passive," "involuntary," "sidestream" or "secondhand"
smoking.
The effects of smoking on smokers have been examined in over 50,000 studies conducted
over the last 25 years. These have shown that cigarette smoking causes lung cancer, chronic
obstructive lung disease, and coronary heart disease. According to the Surgeon General,
cigarette smoking is the chief avoidable cause of death in the United States, with the
number of premature deaths due to smoking estimated at 390,000! annually. The Office on
Smoking and Health reports that smoking causes more premature deaths every year than
cocaine, heroin, alcohol, fire, automobile accidents, homicide and suicide combined.2
The Environmental Protection Agency (EPA) presumes that there is no such thing as a
risk-free exposure to a carcinogen. Unless there is evidence to the contrary, EPA believes
that any exposure to a cancer causing agent-regardless of level-increases the risk of cancer.
The fact that active smoking causes lung cancer, therefore, suggests that nonsmokers
exposed to ETS are also at risk for lung cancer, although at a much lower level than
smokers.
Recently, scientific studies have examined the link between ETS and lung cancer. In 1986,
two major independent reviews examined the impact of ETS on public health.
Commissioned by the U.S. Public Health Service (PHS) under the Surgeon General, and by
the National Research Council (NRC) at the request of EPA and PHS, both groups arrived at
the same conclusion: exposure to ETS significantly increases the risk of lung cancer.
Moreover, there was agreement that ETS exposure substantially increases respiratory illness
in children and aggravates the conditions of people with heart disease.
In 1990, EPA completed a risk assessment of the health effects of ETS. The report examined
the 24 epidemiological studies which have studied the level of risk of lung cancer from
exposure to ETS. The risk assessment reached the following conclusions:
According to the EPA classification of carcinogens, ETS is a Croup A Carcinogen. Croup A
Carcinogens are agents known to cause cancer in humans.
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The number of ETS-attributed lung cancer deaths in U.S. never-smoking adults is
approximately 2,500 annually. The excess number of ETS-related deaths in former smokers
is estimated at about 1,300 annually.
The evidence linking ETS exposure to increased lung cancer incidence can not be attributed
to chance.3
There are also serious non-carcinogenic effects from ETS. In particular, there is a strong
association between ETS and respiratory effects on children and there is mounting evidence
of heart disease mortality in nonsmokers from passive smoking. The evidence of ETS lung
cancer and respiratory disease risks is particularly strong since ETS has been demonstrated
to cause health effects at low levels of exposure.
The public health implications of these findings are significant because of the large numbers
of people exposed. Tobacco smoke is virtually ubiquitous in our society. Studies show that
between 26%4 and 29%5 of the U.S. adult population smokes. This is a decline of almost
one-third since 1964.6 However, the people who continue to smoke smoke more than they
did before. According to the National Research Council, reported cigarette consumption
among heavy smokers has increased from 27.3 to 30 cigarettes per day, and the number of
heavy smokers has steadily increased over the past 30 years. As a result, the number of
cigarettes smoked each year in the United States has increased, and "the nonsmoker who
has close contact with a smoker may be exposed to greater amounts of smoke in 1985 than
in 1955."7
The magnitude of the problem led the Surgeon General to state in 1986 that "the scientific
case against involuntary smoking as a public health risk is more than sufficient to justify
appropriate remedial action, and the goal of any remedial action must be to protect the
nonsmoker from environmental tobacco smoke."* Heeding his words, many nonsmokers
have become concerned about their exposure to ETS, and many businesses and
governments are now taking steps to protect them from it.
This publication is designed to help the non-expert understand the technical basis for
smoking restrictions and to provide guidelines for implementing them. It explains the
physical and chemical nature of ETS, how ETS exposure occurs, how it is measured, and the
health effects of exposure. It examines passive smoking in the workplace and other sites,
and examines legislative, legal, financial, educational and labor concerns. It includes
different strategies for reducing exposure to smoking at the workplace along with case
studies of policies that have been successfully implemented. Finally it contains a list of
resources for those interested in additional information.
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Key Points
What is ETS?
Environmental tobacco smoke (ETS) is primarily a combination of sidestream smoke from
the burning end of the cigarette, pipe, or cigar, and exhaled mainstream smoke from the
smoker.
It contains over 4,000 chemicals, at least 43 of which are known human or animal
carcinogens.
Measuring ETS in the Air and Body
Researchers have found that ETS diffuses rapidly through buildings, persists for long
periods after smoking ends, and represents one of the largest sources of indoor particle
pollution.
Certain constituents of tobacco smoke can be found in the body fluids of nonsmokers who
were exposed, indicating that they have inhaled and retained ETS.
Health Effects of ETS
According to the EPA classification of carcinogens, ETS is classified as a Group A
Carcinogen. Group A Carcinogens are agents known to cause cancer in humans.
ETS exposure is associated with respiratory problems and an increased frequency of ear
infections in young children.
ETS may aggravate the conditions of people with existing heart and respiratory disease.
Since there is no established health-based threshold for exposure to ETS, and since EPA
generally does not recognize either a no-effect or safe level for cancer causing agents, the
Agency recommends that involuntary nonsmoker exposure to ETS be eliminated wherever
possible.
How Big is the Risk from ETS?
The number of ETS-attributed lung cancer deaths in U.S. never-smoking adults is
approximately 2,500 annually. The excess number of ETS-related deaths in former smokers
is estimated at about 1,300 annually.
Reducing Exposure to ETS
Nonsmokers' ETS exposure can be eliminated by: creating enclosed, separately ventilated
smoking rooms with direct external exhaust, or prohibiting smoking indoors.
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ETS exposure can be reduced through a number of techniques. These include: creating
separate walled areas for smokers and nonsmokers with a shared ventilation system,
creating separate unwalled areas for smokers and nonsmokers, air cleaning, air washing
and time separating smokers and nonsmokers. The effectiveness of each of these techniques
in reducing ETS varies.
Regulating Smoking and ETS
The number of communities with legislation restricting smoking jumped from 90 in 1985
to 450 in 1989.
Most ordinances give higher priority to protecting nonsmokers from environmental
tobacco smoke over smokers' preference to smoke.
Developing Effective Smoking Policies
To succeed, smoking policies need the support of top management.
Policies should be developed with employee and labor union input.
Whenever smoking policies are introduced, smoking cessation programs should be made
available to employees who want to quit.
Cost Savings Related to ETS Reduction
Organizations that have implemented policies that restrict or eliminate ETS-exposure
report some cost savings.
Public Attitudes Toward ETS
86% of all Americans (smokers and non-smokers) believe ETS is dangerous to their health.
69% of all Americans (smokers and non-smokers) are annoyed by ETS.
77% of all Americans (smokers and non-smokers) believe that smokers should not smoke
in the presence of non-smokers.
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Recommendations
Based on the significant health risks associated with ETS, organizations should, wherever
possible, eliminate involuntary exposure to ETS at work.
Involuntary exposure to ETS can be eliminated by creating enclosed, separately ventilated
smoking rooms with direct external exhaust, or by prohibiting smoking indoors.
Whenever smoking restrictions are introduced, smoking cessation programs should be
made available to employees.
Employees and labor unions should be involved in the development of smoking control
policies in the workplace.
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Parti:
ENVIRONMENTAL TOBACCO SMOKE: THE PROBLEM
Based on a review and analysis of 24 epidemiological studies which examine the association
between ETS and lung cancer, EPA has confirmed the earlier findings of the Surgeon
General and the National Research Council that ETS causes lung cancer in humans. The
following chapters examine this and other problems created by ETS.
Chapter 1: WHAT IS ETS?
ETS is a complex substance composed of over 4,000 constituents. This chapter reviews its
physical and chemical nature.
Chapter 2: MEASURING ETS IN THE AIR AND BODY
With air monitoring, biomarkers, questionnaires and mathematical models, researchers are
able to assess the presence of ETS in the air and in the human body. This chapter explains
how these techniques are used in order to confirm nonsmokers' ETS exposure.
Chapter 3: HEALTH EFFECTS OF ETS
ETS is a Group A, or known, human carcinogen. This chapter reviews the risk of lung
cancer and other illnesses in nonsmokers as a result of ETS exposure.
Chapter 4: HOW BIG IS THE RISK FROM ETS?
EPA estimates that approximately 2,500 never-smoking adults and 1,300 former smokers die
annually in the United States as a result of exposure to environmental tobacco smoke. This
chapter reviews these and other findings from the EPA risk assessment of ETS.
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CHAPTER 1: WHATISETS?
Environmental tobacco smoke (ETS) is primarily a combination of sidestream smoke from
the burning end of the cigarette, pipe, or cigar, and exhaled mainstream smoke from the
smoker.
Sidestream Smoke (SS) is the smoke emitted by the burning end of cigarettes, pipes and
cigars between and during puffs. The stronger a smoker inhales, the more sidestream
smoke is emitted. For the average smoker, approximately 55% of the cigarette is burned
between puffs, making sidestream smoke the largest constituent of ETS.9
Mainstream Smoke (MS) is smoke inhaled by the smoker. Smokers exhale approximately
18%10 of the smoke they inhale, making exhaled mainstream smoke the second largest
constituent of ETS.
Gases that escape through the cigarette paper as the cigarette is being smoked account for a
relatively small percentage of ETS.
ETS is a cloud of fine particles and liquids suspended in gases. For the purposes of studying
it, scientists have broken it into two components, called "phases." The particulate phase
contains particles approximately one-tenth of a micrometer and larger. Particles that are
smaller than one-tenth of a micrometer are called the gas phase. Together, the particles in
the particulate and gas phases of ETS contain over 4,000 chemicals, at least 43 of which are
known carcinogens.11
DIFFERENCES BETWEEN MAINSTREAM AND SIDESTREAM SMOKE
ETS differs from mainstream smoke in two important ways: particle size and chemical
make-up.
Particle Size
The particles in ETS are smaller than those in mainstream smoke. This allows them to be
absorbed deep into the small air sacs of the lungs.
The average size of mainstream particles is relatively large—seven tenths of a micrometer.12
Because the smoke is very concentrated, the particles tend to clump together, forming even
larger particles as they are inhaled. As a result, they are deposited mainly in the mouth and
larger airways of the smoker's lungs.
Most sidestream particles, on the other hand, are much smaller—between two and four
tenths of a micrometer.13 The smoke is dilute, and the small particles tend to be absorbed
deep into the small air sacs of the lung, where approximately 10% of them remain. The dose
absorbed is small, but after absorption, the chemicals circulate widely in the body, tending to
remain in the body longer than mainstream smoke in active smokers.14
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Chemical Make-Up
Sidestream smoke contains more toxic and carcinogenic chemicals than mainstream
smoke, although the concentrations are much higher in active vs. passive smokers.15 An
analysis of 15 Canadian cigarettes showed that their sidestream smoke contained 3.5 times
the amount of tar and 6.6 times the amount of nicotine than was present in their
mainstream smoke.16 A study compared the amounts of nine toxic compounds in the
mainstream and sidestream smoke of four U.S. cigarettes. In all nine chemicals studied, the
amount in sidestream smoke was significantly higher than the mainstream smoke level.17
The tar and nicotine sidestream yields do not decrease proportionately with the cigarette
mainstream yields.18 This means that manufacturers' efforts to reduce tar and nicotine
consumption for smokers by introducing filtered and low-tar, low-nicotine cigarettes, has
not reduced involuntary exposure to these chemicals. In some cases, it may have actually
increased it.
OTHER CONTAMINANTS
In addition to chemicals that are intrinsic to tobacco, or caused by its burning, cigarette
smoke may also contain pesticides and herbicides. The Surgeon General has observed that
although there has been a reduction in the use of agricultural chemicals, "it is fairly certain
that commercial tobaccos contain up to a few parts per million of DDT, DDD, and maleic
hydrazide; fewer than 20 percent of these contaminants are transferred into the smoke
stream."1?
It is difficult to document exactly which contaminants or additives are present in ETS
because there are no government requirements for the disclosure of tobacco constitutents.
The identity of all contaminants, along with other compounds added in the manufacturing.
process, is regarded as confidential information by cigarette manufacturers.20
HAZARDOUS CONSTITUENTS IN ETS
Many of the chemicals in ETS are known carcinogens, mutagens, toxins or irritants.
Carcinogens and Mutagens
Carcinogens are agents capable of causing cancer. Mutagens are agents capable of causing
permanent, often harmful, changes in cells, some of which may lead to cancer. ETS has
both.
Of the 99 compounds in tobacco smoke that have been studied in detail, at least 43 are
complete carcinogens,21 each able on its own to cause the development of cancer in humans
or animals. Other ETS constituents are tumor initiators, capable of carrying out the first
steps in cancer development. Still others are tumor promoters, able to accelerate the
development of cancer.
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ETS also contains chemicals that are co-carcinogens, able to cause cancer when combined
with another substance. It contains cancer precursors, compounds that pave the way for
formation in the body of other carcinogenic chemicals. And it contains other compounds
that damage the cilia, or cleansing hairs, of the lungs, making them less able to clear the
lungs of deposited tars. This allows cancer-causing chemicals to remain.
In his 1979 report, the Surgeon General cites 27 known tumor initiators, three groups of
tumor promotors, and 18 compounds or groups of compounds that are co-carcinogens as
known components of tobacco smoke.22
Sidestream smoke is known to have significantly higher concentrations of carcinogens and
mutagens than mainstream smoke. For example, the tumor initiators N-nitrosamines are
found in quantities up to 100 times greater in sidestream smoke.23
Chemical analysis of the smoke from pipes, cigars and cigarettes indicates that carcinogens
are found in similar levels in each. Experimental studies have shown that smoke
condensates from pipes and cigars are equally, if not more, carcinogenic than those from
cigarettes.24
Toxins and Irritants
In addition to its carcinogenic constituents, ETS contains a variety of other chemicals that
are harmful to humans. Examples include:
Carbon monoxide is a gas that interferes with the ability of the blood to carry oxygen.
Carbon monoxide levels increase when smokers are present, adding to the body burden of
carbon monoxide from other environmental sources.
Hydrogen cyanide interferes with the action of the tiny cilia hairs in the lungs. It is also an
extremely strong lung irritant and more potent than carbon monoxide in its ability to starve
one of oxygen.
Ammonia is a powerful eye and respiratory irritant.
Nicotine, a poison, is also the addictive agent in tobacco smoke.
Sidestream smoke has been documented to contain more of each of these compounds than
mainstream smoke.25
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Toxic and Cancer-Causing Agents
in Mainstream and Sidestream Cigarette Smoke
Smoke Constituents
Tar (mg)
Nicotine (mg)
Carbon monoxide
(mg)
Catechol (tig)
Benzo(a)pyrene (mg)
Ammonia (ng)
Nltrosodlm-
ethylamine (ng)
Nltrosopyr-
rolidlne (mg)
Nitrosonor-
nlcotlne (ng)
4-(methylnltrosamino)-l
(3-pyrldyl)-1-butanone
Unflltered
Cigarette
1112 0:1,
22.6
2; 04
4.62
13.2
28.3
vif4T.9:-':-'
58.2
26.2
67.0
76.0
524
31.1
735
64.5
117
1007
857
. 425
1444
Filtered
Cigarette
A
15.6
24.4
1;50
4.14
13.7
36.6
71.2
89.9
17.8
45.7
19.4
893
4.3
597
10.2
139
488
307
180
752
Filtered
Clgaretti
B
;f:f6;.8%
20.0
mow
3.54
9.5
33.2
26; 9
69.5
12.2
51.7
34.0
213
12.1
611
32.7
233
273
185
56.2
430
Low Tar
Cigarette
with
Perforated
Filter
w,o.9m
14.1
iiiO.15^-
3.16
1.8
26.8
9.1W:
117
W:'2.2^':
44.8
40.4
236
4.1
685
13.2
234
66.3
338
17.3
386
Mainstream Smoke
Sidestream Smoke
Source: NAS, 1986
10
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CHAPTER 2: Measuring ETS in the Air and Body
Historically, when researchers studied environmental air pollutants, they focused on large
outdoor sources such as industrial emissions, toxic wastes, and auto exhaust. They used
stationary monitors to determine what pollutants were present, and in what quantities.
Recently, however, scientists have turned attention indoors. Because many people spend
up to 90% of their time inside, indoor air forms the largest part of what we breathe. Thus,
even small amounts of indoor pollutants may cause as much risk as vast amounts of those
materials outside.26
Recent technological advances make the measurement of many indoor pollutants possible.
Sensitive monitors enable scientists to analyze the chemical and particulate composition of
indoor air. Sophisticated portable monitors permit them to monitor an individual's
personal airspace as he or she moves through numerous environments over several hours
or days. And detecting pollution-derived chemicals in an individual's saliva, urine, or
blood enables scientists to confirm exposure. Scientists are now using these techniques as
well as mathematical models to study ETS-exposure.
DEFINING EXPOSURE
Nonsmokers' exposure occurs when they encounter ETS-polluted air. The extent of their
exposure is determined by how long they breathe the polluted air, and by the concentration
(or density) of ETS in the air. Concentration is affected primarily by the number of smokers
present, the rate at which they smoke, the ventilation conditions in the room or building,
and how large a space it is.
When people are exposed to ETS, some smoke particles remain in the body while others are
exhaled. Those that remain are called the dose. A person's dose is affected by the amount
of smoke to which he or she is exposed, the duration of exposure, and breathing rate.
People engaged in physical activity, for example, will inhale and retain larger quantities of
air than those who are motionless. Currently, scientists are able to measure a person's
exposure to ETS and the dose of certain constituents, but are not yet able to directly measure
the total dose of smoke inhaled and retained.
ASSESSING ETS EXPOSURE
Researchers have several ways of assessing ETS exposure.
Air monitors measure the amount of certain constituents of smoke in a given air space.
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Biological markers are indicators of exposure in a person's body fluids.
Questionnaires ask people about their exposure.
Mathematical models calculate the degree of exposure that is likely in a given airspace.
Since 1981, approximately 50 studies have been done of ETS concentrations in buildings.
Using these methods, researchers have found that ETS diffuses rapidly through buildings,
persists for long periods after smoking ends, and represents one of the major sources of
indoor particle pollution.
Air Monitoring Studies
Air monitoring is done two ways. Stationary monitors are used to measure the amount
and types of air-borne pollutants in a particular space; personal monitors are portable gauges
carried by individuals to measure the pollutants they are exposed to as they move through a
variety of environments over a period, of lime.
However, neither type of monitor measures all the components of ETS because the number
of constituents is too large. Instead, surrogates are used, chemicals that are accurate
indicators of the presence and quantity of ETS. The most commonly used surrogate is
respirable suspended particulates (RSP). RSP refers to the tiny particles, small enough to be
inhaled deeply into the lungs, that are present in all air. These particles come from dust,
cooking, household chemicals and many other objects in our environment. However,
studies show that where smoking is permitted, ETS is the major contributor to RSP in
indoor air.27
Stationary air monitor studies have compared RSP levels in the homes of smokers and
nonsmokers. They found that each smoker generates 25 to 35 micrograms of RSP per cubic
meter of air (jig/m3). Homes with two or more heavy smokers frequently exceed the
federal 24-hour outdoor particle standard of 260 ng/m3. In homes with heavy smokers,
short-term particulate concentrations of 500 to 1,000 |ig/m3 are not uncommon.28
Studies of public buildings duplicate these findings. Levels in non-smoking buildings, such
as churches, libraries and museums, had low levels of RSP. By contrast, restaurants, bars
and bus stations, where smoking is permitted, had RSP levels ten to twenty times as high.29 3°
The highest RSP levels were found in designated smoking areas, where the level of RSP
correlated with the number of cigarettes smoked. One office building had RSP levels of 11
jig/m3 in its nonsmoking offices, and 520 ug/m3 in a smoking lounge.31 In the smoking
section of an airplane, RSP levels were five times higher than in the nonsmoking section,
reaching 1,000
Personal air monitor studies found similar results. Nonsmokers who were exposed to
smokers recorded significantly higher levels of RSP than did those who were not exposed.
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This was true for children with smoking parents (compared to children of nonsmokers),
and for adults exposed to smoke both at home and at work.33 M
Biomarker Studies
Some of the constituents unique to tobacco smoke can be found in the body fluids of people
who were exposed to smoke, indicating that they have inhaled and retained ETS. Scientists
use these chemicals as biomarkers, indicators of ETS exposure. They are not direct
measures of the total dose of ETS the individual inhaled.
Cotinine is the most commonly used biomarker. Since it is totally unique to tobacco, it is a
reliable indicator of ETS exposure. Nicotine breaks down in the body into cotinine, a
chemical easily measured in blood, saliva and urine.
Studies show that cotinine levels are higher in people who report they have been exposed
to tobacco smoke than in those who report they have not. Studies have shown a
relationship between cotinine levels and ETS exposure.35 Cotinine levels show that infants
absorb nicotine from passive smoking as well as from breastmilk.36 Cotinine has also been
measured in the urine of people who were unaware they had been exposed. In fact, in
several British studies, nearly all nonsmokers had measurable cotinine levels, regardless of
reported exposure. Positive cotinine concentrations in three out of four nonsmokers,
including persons reporting no exposure to tobacco smoke in the measuring period (up to a
few days, depending on the body fluid tested), demonstrate the ubiquity of ETS exposure in
nonsmokers.37
Other Surrogates
While RSP and nicotine are the most widely used surrogates for ETS, researchers have
studied other surrogates as well.
Air monitor studies have shown nicotine levels considerably greater in homes with
smokers than in homes without.38
Benzene, a hazardous air pollutant which is regulated in outdoor air by EPA because it
causes leukemia in humans at occupational levels, has been found at average levels 50%
higher in homes with smokers than in homes without.39 People exposed to ETS at work
over 50% of the time, have shown significantly higher breath concentrations of benzene
than those exposed less often.40 For smokers, cigarettes are the greatest source of benzene
exposure in the environment. For passive smokers, ETS is a significant source of benzene
exposure.
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Questionnaires
Surveys or questionnaires are frequently used to determine ETS exposure. They typically
inquire about smoking habits of family, friends and co-workers and the level of the
resulting ETS exposure. Asking people about their ETS exposure has several potential
limitations. First, questionnaires usually only can address short term exposure and do not
provide an indication of dose over a lifetime. Second, most questionnaires have limited
the discussion of ETS exposure to the home, while a large amount of the exposure may take
place away from the home (at work or in public places). Third, it is often difficult to
measure and quantify ETS exposure at work. Even with these limitations, questionnaires
have proved to be an effective tool to distinguish between populations that receive a high
level of exposure and those that receive a smaller level.
Mathematical Models
Mathematical models involve measuring and analyzing a number of factors to determine
total ETS exposure from a given space. The first step in the process requires measuring with
monitors the concentration of various ETS constituents. These pollution levels are
combined with information concerning the amount of time an individual will spend in the
area to develop an average level of exposure. Finally, the calculations review the factors
which control the contaminant levels in the space (these may include the number of
cigarettes smoked, amount of ventilation in the space, etc.). Mathematical models have
been developed and tested for accuracy and have proved to be a reasonable way to estimate
ETS exposure.
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CHAPTER 3: Health Effects of ETS
Studies show that for healthy adults, the acute respiratory effects of short-term ETS
exposure can vary from none to moderate irritation. Regular long-term ETS exposure can
cause chronic irritation and lung cancer. Susceptible sub-populations (those with special
sensitivity to ETS) are at greater risk. Researchers are also examining the effects of ETS on
the cardiovascular system and other parts of the body.
IRRITATION
Whereas short-term visitors to a smoking area may be annoyed by tobacco smoke odors,
nonsmoking occupants of the area are more likely to complain about burning, itchy eyes.41
This occurs when the water-soluble chemicals in tobacco smoke dissolve in the liquid of the
eyes, causing reddening, itching and tearing. For many people the effect is annoying; for
some it can become incapacitating.
ETS can also cause irritation in the nose and throat when the smoke's water-soluble
chemicals dissolve there, irritating the mucous membranes. The result is generally a sore
throat or cough. Other short-term effects of ETS exposure include wheezing, dizziness,
headaches or nausea.42 Studies in both laboratories and real-life situations show that
irritation increases with exposure, although a few studies have suggested that irritation
levels off after about an hour.43
LUNG CANCER
Since active smoking causes lung cancer, it is reasonable to believe that exposure to ETS
might also increase a person's risk of developing the disease. To investigate that possibility,
several researchers have conducted epidemiological studies of exposed nonsmoking
populations.
In early 1981, researchers in Greece reported a significant increase in lung cancer among
nonsmoking women married to smokers.44 At about the same time, similar results were
reported from a methodologically different study in Japan. 45
These three studies fueled serious concern about the lung cancer risks of ETS. As a result,
in the mid-1980's, the Surgeon General and the National Research Council each convened
scientific panels to study the matter further. Their reports were issued in 1986. Both
concluded that passive smoking causes lung cancer.
The Surgeon General based his conclusion on three facts: active smoking causes lung
cancer; there are qualitative similarities between ETS and mainstream smoke; and
epidemiological studies show a positive association between lung cancer deaths in
nonsmokers and ETS exposure. The Surgeon General stated, "Involuntary smoking is a
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cause of disease, including lung cancer, in healthy nonsmokers." He added, "In examining
a low-dose exposure to a known carcinogen, it is rare to have such an abundance of
evidence on which to make a judgment."46
The National Research Council reached the same conclusion in a somewhat different way.
They found that laboratory studies show that it is biologically plausible for ETS to cause
cancer in human cells, and that epidemiological studies confirm a link between lung cancer
in nonsmokers and ETS exposure.47
In 1989, a formal risk assessment of lung cancer and ETS was undertaken by EPA's Offices of
Research and Development and Air and Radiation. After review and analysis of 24
epidemiological studies,48 they concluded that ETS is a Group A carcinogen according to the
EPA's classification of carcinogens. Group A Carcinogens are agents known to cause cancer
in humans. This comprehensive review also concluded that the epidemiological evidence
linking ETS exposure to increased lung cancer incidence cannot be attributed to chance.49
Since there is no established, health-based threshold for exposure to ETS and since EPA
generally does not recognize either a no-effect or safe level for cancer causing agents, the
Agency recommends that exposure to ETS be eliminated wherever possible.
The number of lung cancer deaths attributable to ETS exposure is discussed in the next
chapter.
RESPIRATORY DISEASE
Respiratory disease has also been linked to ETS exposure in children. ETS may also cause
respiratory disease in adults. Several studies have reported small declines in lung function
in nonsmokers exposed to ETS, but whether ETS exposure alone would cause chronic
obstructive lung disease in otherwise healthy adults is unclear.
IMPACT ON SUSCEPTIBLE POPULATIONS
The strong irritants in ETS may exacerbate conditions in especially sensitive individuals.
These include children and the approximately 10% of the population suffering from
asthma, emphysema, bronchitis and chronic sinusitis. Also potentially at risk are people
with allergies, other respiratory conditions, heart disease and circulatory disease. All of
these conditions may be aggravated by exposure to ETS. These are discussed in more detail
below.
CHILDREN
Studies have documented that 54% to 75% of American children live with smoking adults.50
Children, therefore, represent an extremely large exposed population. In fact, exposure to
ETS may begin in utero since fetuses of nonsmoking mothers have shown absorption of .
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ETS constituents.51 ETS exposure continues after birth, as infants drink breast milk
contaminated with ETS constituents and breathe ETS polluted air.
While tobacco smoke absorption can be dangerous for adults, it is especially so for children.
Children have been shown to absorb more nicotine from ETS than adults,52 they are
exposed over a longer period of time, and their developing respiratory systems may be
especially vulnerable to toxic damage.
The most common health effects in children are symptoms of respiratory irritation and
infection. Children of smoking parents wheeze more, cough more, have more phlegm, and
have higher rates of pneumonia and bronchitis than children of non-smoking parents.
They are also hospitalized more often for these respiratory infections. The level and
frequency of illness correlates with the number of cigarettes smoked by the mother
(presumably a father's smoking has less bearing on his child's health because he typically
spends less time with the child).
ETS exposure in children is associated with mild impaired lung growth. Some studies
suggest that ETS exposure in utero may alter the growth pattern of the fetal lung, which
may cause increased respiratory infections in later life.53 And children with at least one
smoking parent seem to have slower growth of lung function than do children with
nonsmoking parents.54
A third effect is ear infections. Young children exposed to ETS have higher rates of chronic
ear infections and middle-ear effusions than children who are not exposed.55
While the specific effects of ETS on children are still being investigated, the general
conclusion is clear. In the words of the National Research Council, "it is prudent to
eliminate ETS exposure from the environments of small children."56
ASTHMATICS
Some people with asthma report that exposure to ETS increases their symptoms, and
several studies have documented this effect. However, other studies have shown little
difference between asthmatics' reactions to ETS and that of healthy nonsmokers. At this
time, the data are too limited to draw conclusions.57 58
PEOPLE WITH HEART DISEASE
Some studies have shown that ETS can aggravate the conditions of people with existing
heart disease. By increasing the levels of carboxyhemoglobin and carbon monoxide in the
blood, ETS decreases the ability of the heart to contract and pump.59 This raises the blood
pressure of people with heart disease.60 A complete analysis of the data linking ETS and
heart disease has not been conducted by EPA.
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PEOPLE WITH ALLERGIES
People with allergies (as well as the allergy-prone) frequently develop allergic-type reactions
to ETS: headache, sore throat, wheezing and nausea. This has prompted researchers to
investigate the possibility of a tobacco smoke allergy; however, it is still too early to know if
such an allergy exists.61
OTHER POTENTIAL HEALTH EFFECTS
HEART DISEASE
The data available at the present time are insufficient to conclude that ETS causes heart
disease but it appears that some association may exist. Although several epidemiological
studies62 that have examined the relationship between ETS and heart disease have
concluded that ETS exposure is associated with increased risk of heart disease, the
relationship between the two is still a subject of debate within the scientific community. As
noted above, EPA has not conducted a full review of this literature.
CANCER AT OTHER SITES
A small number of studies have examined the relationship between ETS exposure and
cancer at sites other than the lung. At this point the data are too limited to be conclusive.
However, some studies of nonsmoking women found higher cancer rates among those
whose husbands smoked than among those whose husbands didn't. These cancers
included brain tumors and nasal sinus cancers,M genital, breast and endocrine cancers,64 and
cervical cancer.65 Studies of children have found increased risk of cancer in those whose
parents smoke,666768and a study of infants found that those whose mothers were exposed to
ETS while pregnant had a higher risk of developing brain tumors.69 Additional research is
needed in this area.
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CHAPTER 4: How Big is the Risk From ETS?
To estimate the number of nonsmokers who die from lung cancer each year due to ETS
exposure, EPA conducted a comprehensive risk assessment of ETS in 1989-90 entitled
"Health Effects of Passive Smoking: Assessment of Lung Cancer in Adults and Respiratory
Disorders in Children".70 The study reviewed and analyzed the data from 24
epidemiological studies on ETS and lung cancer, including those that have been done since
the 1986 reports of the Surgeon General and the National Research Council.71
THE EPA RISK ASSESSMENT
The risk assessment focused on never-smoking women married to smokers because this is
the most studied group. The report estimates that approximately one-fourth of all lung
cancer deaths in never-smoking women are due to ETS exposure. This equals
approximately 1,750 deaths annually in U.S. never-smoking women from all ETS exposure.
The data on ETS-related lung cancer deaths in never-smoking males are sparse. The
available evidence suggests that the individual risks for men and women are comparable,
although the total number of men never-smokers exposed to ETS is considerably smaller
than the number of exposed never-smoking women. This translates into approximately
750 deaths in U.S. never-smoking males annually from all ETS exposure. If the same risks
hold for ex-smokers, ETS exposure would be responsible for an additional 1,300 deaths
annually for both sexes.
Therefore, the total number of all ETS attributed lung cancer deaths in nonsmoking U.S.
women and men is approximately 3,800 annually. The number of ETS-attributed
lung-cancer deaths in current smokers has not been estimated, nor has the effect of home
vs. occupational or social exposures been compared.
COMPARING RESULTS WITH PREVIOUS STUDIES
In a recent review72 of nine previous risk assessments on ETS, estimates of lung cancer
deaths in eight of these were in close agreement, averaging approximately 5,000 deaths per
year in nonsmokers exposed to ETS. These assessments were done in different ways, some
quantifying ETS exposure in terms of "cigarette equivalents" and using mathematical
models to extrapolate down to environmental levels. The EPA risk assessment estimates
the percent of the risk attributable to ETS, based on actual studies at true environmental
levels. This eliminates the need for mathematical extrapolation models. EPA estimates of
attributable risk, approximately 25% of all nonsmoker lung cancer deaths, is also consistent
with those of others, including the NRC.
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PUBLIC HEALTH IMPLICATIONS
Based on EPA's estimate that approximately 2,500 never smoking adults and
approximately 1,300 former smokers die from lung cancer each year as a result of exposure to
environmental tobacco smoke, ETS is an important public health concern. Because of the
ubiquity of tobacco smoke in our society, even a small increase in the risk of lung cancer
from exposure to ETS translates into a significant health hazard to the U.S. population.
3800 Non-Smoking People Estimated
to Die Annually
from ETS-Attributed Lung Cancer
1750 Never-Smoking Females
1300 Ex-Smokers
750
Never-Smoking
Males
U.S. EPA, 1990
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PARTn
ENVIRONMENTAL TOBACCO SMOKE: THE SOLUTIONS
A variety of strategies have been developed to mitigate nonsmokers' exposure to ETS.
These strategies vary in effectiveness, implementation cost and inconvenience to smokers.
The following chapters explore issues to consider in policy development, the range of policy
alternatives and successful implementation strategies to reduce or eliminate involuntary
ETS exposure.
Chapter 5: REDUCING EXPOSURE TO ETS
Nonsmokers' ETS exposure can be eliminated by creating enclosed, separately ventilated
smoking rooms with direct external exhaust, or by prohibiting smoking indoors. ETS
exposure can be reduced through a number of techniques including separate walled areas
for smokers and nonsmokers with a shared ventilation system, separate unwalled areas for
smokers and nonsmokers, air cleaning, air washing and time separation. The effectiveness
of each of these strategies will be reviewed in this chapter.
Chapter 6: REGULATING SMOKING AND ETS
There are federal, state and local regulations that have an impact on ETS exposure. There
have also been lawsuits concerning involuntary exposure to ETS in the workplace and suits
by smokers to establish a right to smoke. This chapter examines the impact of legislation
and litigation on involuntary exposure to ETS.
Chapter?: DEVELOPING EFFECTIVE SMOKING POLICIES
The workplace may be the greatest source of ETS exposure for many nonsmoking adults.
However, ETS exposure can be effectively reduced or eliminated from the workplace with
carefully developed smoking policies. This chapter discusses strategies for developing
effective policies.
Chapter 8: COST SAVINGS RELATED TO ETS REDUCTION
Organizations that introduce smoking policies report a variety of cost savings. This chapter
reviews cost savings directly and indirectly related to reducing ETS in the workplace.
Chapter 9: PUBLIC ATTITUDES TOWARD ETS
Public opinion tends to support smoking restrictions in public places. This chapter reviews
the major public opinion surveys in this area.
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CHAPTER 5: Reducing Exposure to ETS
The ability of ETS to spread quickly through the air makes it virtually ubiquitous in indoor
spaces where smoking is permitted. However, ETS exposure can be eliminated or reduced
through a number of techniques. These include: prohibiting smoking indoors, creating
separate smoking lounges with separate ventilation, creating separate walled areas for
smokers and nonsmokers with a shared ventilation system, creating separate unwalled
areas for smokers and nonsmokers, air cleaning, air washing and time separating smokers
and nonsmokers. The effectiveness of each of these techniques in reducing ETS varies.
This chapter discusses each of these techniques. How they can be integrated into successful
smoking policies is discussed in Chapter 7.
Prohibit Smoking Indoors
The most effective way to eliminate ETS exposure for nonsmokers is to prohibit smoking
indoors. This is also, generally, the least expensive method of eliminating ETS from indoor
air because it doesn't require changes to the existing ventilation system and may also reduce
long term energy costs. However, a smoking prohibition may be inconvenient to those
smokers who continue to smoke and must leave the building to do so.
Part Three of this guide contains case studies of organizations that successfully prohibited
smoking in the workplace.
Create Separate Smoking Lounges With Separate Ventilation
Creating enclosed smoking areas with separate ventilation can eliminate nonsmokers'
exposure to ETS without forcing people who want to smoke to go outside. A smoking
room can be designed to protect nonsmokers from the health risks of ETS and to provide
smokers additional ventilation while they are inside the room.
To be properly ventilated, a smoking room should meet three requirements:
The smoking room should have a separate ventilation system. This means that air from
the room should be immediately exhausted outside rather than being recirculated through
the building. The average building recirculates the vast majority of its air supply.
The room should have at least 60 cubic feet per minute (cfm) of outdoor air per smoker to
control ETS odors. The average for the typical office is 5-20 cfm of outdoor air, which is
inadequate to effectively reduce the level of ETS when smokers are present.
The room should be slightly negatively pressurized to prevent backstreaming of smoke into
the nonsmoking areas of the building. This means that the air pressure inside the room
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should be somewhat lower than the air pressure outside. The average building is positively
pressurized.
Part Three also contains examples of organizations that have successfully established
separately ventilated, indoor smoking rooms.
Create Separate, Walled Areas For Smokers and Nonsmokers With a Shared
Ventilation System
A common mitigation strategy is to create separate areas for smokers and nonsmokers, each
walled off from the other. This may reduce nonsmokers' ETS exposure. However, it does
not eliminate ETS pollution. As long as the two spaces share a ventilation system, their
occupants will breathe the same air. Polluted air from the smoking rooms will be
recirculated to nonsmoking areas.
A second problem with this strategy is that ETS diffuses easily through doorways and
windows. Therefore the smoke will not remain in the room, but will seep into neighboring
nonsmoking spaces 73
Create Separate, Unwalled Areas For Smokers and Nonsmokers
This is the most common mitigation strategy, and is often employed in restaurants.
Smokers and nonsmokers share one space which is divided into "smoking" and
"nonsmoking" areas.
This arrangement may be preferable to seating smokers and nonsmokers side by side,
because it reduces the amount of ETS in the immediate area. However, it does not
eliminate ETS exposure. ETS particles spread readily throughout a room, polluting
nonsmoking as well as smoking areas. For this reason, the Surgeon General has stated that
"simple separation of smokers and nonsmokers within the same air space may reduce, but
does not eliminate, the exposure of nonsmokers to environmental tobacco smoke."74
Air Cleaning
"Air cleaning" is a generic term that refers to three general types of devices.
Mechanical filters: these use a filter to trap particles. There are two main categories of
mechanical filters. Flat filters, which will efficiently collect large particles but remove only a
small percentage of respirable-sized particles and pleated filters which generally attain
greater efficiency in capturing respirable-sized particles.
Electronic air cleaners: these trap charged particles using an electrical field.
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Ion generators: these use static energy to charge the particles. Once charged the particles are
attracted to walls, floors, table tops, draperies, occupants, and other surfaces. Some ion
generators contain a collector to attract the charged particles back to the unit.
Some of the newer machines on the market are referred to as "hybrid" devices. They
contain two or more of the types of particle removal mechanisms discussed above.
Mechanical filters, for example, may be combined with an electrostatic precipitator or an ion
generator.
Air cleaners can be in-duct devices, installed within a building's heating, ventilating and air
conditioning (HVAC) system, or can be free-standing, portable devices. The effectiveness of
air cleaners in removing pollutants from the air depends on both the efficiency of the
device itself (the percentage of the pollutant removed as it goes through the device) and the
amount of air handled by the device.
Portable air cleaners vary in size and effectiveness in pollutant reduction capabilities. They
range from relatively ineffective table-top units to larger, more powerful console units. In
general, units containing either electronic air cleaners, negative ion generators, or pleated
filters, and hybrid units containing combinations of these mechanisms, are more effective
than flat filter units in removing ETS particles.
It should also be noted that although some air-cleaning devices may be effective at reducing
ETS particles, many of the gaseous pollutants are not effectively reduced.75 In addition, gases
may be reemilted from tobacco smoke particles trapped by the air cleaner, since the particles
are primarily liquid.76
Air Washing
Air washing is a process in which air is sprayed with water to increase its humidity. Some
people report that washed air smells fresher than unwashed air, perhaps because some of
the water-soluble particles in ETS are dissolved. As a result, washed air may need less
ventilation to control tobacco odor. But washing does not significantly reduce the number
of ETS particles in the air and its gaseous pollutants, so it is relatively ineffective for
mitigating the health effects of ETS exposure.77
Time Separating Smokers and Nonsmokers
Time separation is a strategy that seeks to mitigate ETS exposure by having smokers and
nonsmokers use the same space at different times. While this will reduce nonsmokers1
acule exposure, it will not eliminate it because of the persistence of ETS. ETS particles cling
to room surfaces and remain in the air for several hours after smoking has stopped. People
entering a space where smoking occurred several hours earlier will often still be exposed to
ETS particles and gases.
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SIDEBAR
EXAMINING YOUR VENTILATION SYSTEM
The type of smoking policy you adopt may be influenced by the design of your ventilation
system. Before you decide on a policy, talk to your landlord or building engineer to learn
how the system works and how it can best meet your needs. Some things to look at are:
Ventilation zones. In a central ventilation system, air recirculates through all floors of a
building: you breathe your neighbors' air. Can you create separate ventilation zones for
your area?
Smoking room options. Are certain areas better suited for smoking rooms than others?
Requirements. Does your city or state have different ventilation requirements for smoking
and nonsmoking spaces?
Cost What would it cost to establish separately ventilated smoking rooms? What are the
on-going energy costs of maintaining them?
Maintenance. To function properly, ventilation systems must be cleaned and serviced
regularly. Is your system being adequately maintained?
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CHAPTER 6: Regulating Smoking and ETS
A variety of regulatory controls have been developed dealing with ETS exposure. They
include, federal regulations, state and local ordinances, and litigation.
The premise on which these controls are based is that all citizens have a "common law"
right to a safe and healthy environment (common laws are unwritten laws whose binding
power comes from their longstanding, universal acceptance). This implies an environment
reasonably free from toxins. What happens when the common law right of nonsmokers to
breathe clean air conflicts with the wishes of smokers to smoke in public?
The trend in legislation is toward giving precedence to the health of nonsmokersand to
give higher priority to protecting nonsmokers from environmental tobacco smoke over
smokers' preference to smoke.
At the same time, several legal opinions have indicated that smoking in public is not a
protected legal right. This is not to say that smoking is illegal, but rather that it is a privilege
that may be permitted or restricted in various settings.
FEDERAL REGULATIONS
Regulation of Tobacco and Tobacco Products
Some of the hazardous chemicals in ETS are regulated by government agencies when found
in other contexts. For instance, benzene, DDT, arsenic, vinyl chloride, carbon monoxide,
nitrogen oxide, radionuclides and lead are all regulated by EPA. The Food and Drug
Administration regulates the nicotine in nicotine gum. The Occupational Safety and
Health Administration (OSHA) also regulates 4-aminobiphenyl and 2-naphthylamine.
Levels of all of these chemicals have been documented in ETS.78
However, tobacco and tobacco products have been largely exempted from federal regulation.
The Tobacco Use in America Conference, sponsored by the American Medical Association,
conducted a review of Federal regulation of tobacco products. The Final Report of the
Conference observed that "Tobacco regulations are a haphazard patchwork of incomplete
and diminishing control...the reasons for the lack of regulation are historical, economical
and political — not logical."79
Tobacco products are largely exempted from Federal regulation despite the fact that 43
constituents of tobacco smoke have been found to be carcinogenic in animals or humans.
According to the National Academy of Sciences, "cigarette smoke contains known human
and animal carcinogens that would be strictly regulated if the source were something other
than tobacco."»"
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Smoking Restrictions in Public Transportation
While the federal government has not issued general regulations restricting smoking in
public places, smoking has been restricted or eliminated on many forms of public
transportation. Congress has banned smoking on all U.S. domestic airline flights of less
than six hours, the Interstate Commerce Commission limits smoking on buses to the rear
30% of seats and Amtrak prohibits smoking on trains except in designated areas.
Smoking Restrictions in Federal Buildings
In 1986, the General Services Administration required all federal agencies to implement
smoking control policies in their worksites. It developed standards that those policies must
meet, but left the development of the policies to the individual agencies. The regulations
vary from agency to agency.
STATE AND LOCAL ORDINANCES
Forty-three states81 and 450 local communities82 have adopted laws or regulations
restricting smoking. While these laws vary, most address the following four areas: what
smoking materials are included and where smoking may and may not take place; signage;
who has the responsibility to enforce the regulations; and penalties for violating the
regulations.
Where Smoking is Permitted
Most smoking control laws prohibit smoking in: public transportation vehicles, elevators,
public waiting areas, health care facilities, libraries, museums, theaters, auditoriums, and
swimming pools.
Many also prohibit smoking in: public schools, supermarkets, restaurants and department
stores. Some include government offices. Some prohibit smoking in all enclosed public
places except those listed in the ordinance. Generally exempted from the regulations are:
bars, designated smoking areas of restaurants, private residences and hotel rooms.
An area where regulations vary greatly is the private workplace. Some ordinances make no
mention of it; others require that employers provide smoke-free areas for nonsmoking
employees to the greatest extent possible without incurring any expense. Some require all
private employers to implement a smoking policy; others require employers to give the
wishes of nonsmokers priority over those of smokers.
In general, most ordinances give precedence to nonsmokers when the preferences of
smokers and nonsmokers collide. 83
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Signage Requirements
Many ordinances specify that signs must be posted prominently in all areas where smoking
is restricted so people are aware of the regulations.
Enforcement
Enforcement of the regulations generally falls to the state or local health department.
Owners of public property where restrictions apply are required to implement and enforce
them on their premises. Failure to do so generally subjects the owner to penalties,
frequently higher than those imposed on the offending smoker.
Penalty Provisions
Penalty provisions vary from state to state. The stiffest are in Minnesota, where people
breaking the law are subject to a $500 fine or 90 days in jail. Colorado and Massachusetts
impose no penalties at all. Other states charge fines of $5 to $200.
LITIGATION
A few individuals who felt they had not been adequately protected from ETS have sought
relief through litigation. The small number of suits claiming damage from ETS in public
places have been denied, generally on the grounds that individuals need not stay in a public
place that causes them distress. However, suits brought by smoke-sensitive employees who
must sit in smoke-filled offices each day have met with some success. Several dozen
lawsuits have been filed on a variety of grounds, with mixed results.
Common-Law Suits
Several suits have claimed that employers were negligent in upholding an employee's
common law right to a safe work environment. The first, and landmark, case was Shimp v.
New Jersey Bell Telephone.6* It was brought in 1976 by Donna Shimp, an employee of New
Jersey Bell. According to her physicians, Shimp was allergic to cigarette smoke: her passive
smoking caused severe nose, throat and eye irritation, headaches, nausea and vomiting.
When Ms. Shimp used company grievance procedures to complain about the problem, the
company installed an exhaust fan near her desk. When the fan didn't help, Ms. Shimp was
invited to move to a different location, which entailed a demotion and a decrease in pay.
After unsuccessfully seeking relief through several government agencies, Shimp sued the
company for injunctive relief: she asked the court to require Bell to eliminate smoke from
her work area.
The judge agreed. Noting "the toxic nature of cigarette smoke and its well known
association with emphysema, lung cancer and heart disease," he concluded: "The evidence
is clear and overwhelming. Cigarette smoke contaminates and pollutes the air, creating a
health hazard not merely to the smoker but to all those around her who must rely upon the
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same air supply. The right of an individual to risk his or her own health does not include
the right to jeopardize the health of those who must remain around him or her in order to
properly perform the duties of their jobs. The portion of the population which is especially
sensitive to cigarette smoke is so significant that it is reasonable to expect an employer to
foresee health consequences, and to impose upon him the duty to abate the hazard which
causes the discomfort."
The judge also noted the irony that the company had already prohibited smoking around its
machinery to prevent damage from tobacco smoke. He observed, "a company which has
demonstrated such concern for its mechanical components should have at least as much
concern for its human beings." He then ordered Bell to prohibit smoking in Shimp's work
area.
By legally recognizing the dangers of cigarette smoke, Shimp established a precedent for
future cases. However, this did not guarantee victory to future plaintiffs. In 1982, Paul
Smith, an employee of Western Electric Company, suffered severe health effects from
exposure to tobacco smoke at work. The company offered him an respirator or a job in the
computer room (where smoking was prohibited) with a pay cut of $500 a month. He sued,
and asked the court to require Western Electric to eliminate tobacco smoke from his work
area. The trial court refused to hear the case. Smith appealed, and the Appeals Court, citing
Shimp, ruled that "smoking in the work area is hazardous to the health of employees in
general and plaintiff in particular." The Court stated that an injunction against smoking
may be appropriate, and remanded the case to the trial court. The trial court, however,
ruled in favor of Western Electric because it was not convinced that all of Smith's problems
stemmed from ETS exposure. Smith did not appeal.85
A 1983 case, Gordon v. Raven Systems & Research, //ic.,86 also handed the employee a
defeat. Gordon, who claimed sensitivity to tobacco smoke, was terminated by Raven
Systems & Research when she refused to work in a smoky room. She sued for monetary
damages. The court recognized Gordon's sensitivity to ETS, but concluded that she had
failed to present sufficient evidence proving its harmfulness to other employees, ruled that
"the common law does not impose upon an employer the duty or burden to conform his
workplace to the particular needs or sensitivities of an individual employee." Gordon lost
her case. However, some lawyers believe rulings like Smith and Gordon may be less likely
in the future given the evidence against ETS that has developed since the cases were heard.
In 1985, in the case of Marie Lee v. (the Massachusetts) Department of Public Welfare a state
employee sued her employer to eliminate tobacco smoke from her work area. She was
joined by a pregnant woman and an ex-smoker with emphysema. The court granted them
a temporary order requiring the employer to prohibit smoking in their work areas. At that
point a third party intervention was filed by a smoker who claimed that because she was
addicted to tobacco, she would be unable to do her job if smoking were banned. The court
dismissed the smoker's challenge as having no merit. An out-of-court settlement was
negotiated providing full protection for the nonsmokers.87
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"Handicapped Rights" Suits
Some smoke-sensitive employees have sued for relief under the Federal Rehabilitation Act
of 1973. According to the Act, a "qualified handicapped individual" is entitled to
"reasonable accomodation" for his or her disability. In two cases, employees claimed that
sensitivity to tobacco smoke qualified them as disabled, and asked that smoke be eliminated
from their worksites. In the case of Pletten v. Department of the /\rmy,88 the Merit
Systems Protection Board ruled that Pletten was handicapped as a result of his smoke
sensitivity, but that because he moved around during the day, the only effective way to
eliminate smoke in his worksite would be to prohibit smoking throughout the facility.
That, the Board felt, would be "undue hardship" for his employer. In the case of Vickers v.
Veterans Administration,89 the court held that Vickers was handicapped as a result of his
smoke sensitivity, but that the employer had already made "reasonable accomodation" to
his handicap by creating a separate smoking area and installing additional ventilation.
Although both plaintiff's requests were denied, these cases are important because they
establish the precedent of nonsmokers qualifying as disabled under the Rehabilitation Act.
The Act covers all federal employers, federal grant recipients, and federal contractees with
contracts over $2,500.
Disability Retirement Suits
In 1982, Irene Parodi, who is asthmatic, was awarded disability retirement benefits by a
federal appeals court because her employer, the federal government, had failed to provide a
safe, smoke-free work environment. The court held that a person with an "environmental
limitation"—that is, someone whose environment limits her ability to perform—can
qualify for such benefits. In a settlement, the government paid Ms. Parodi $50,000 and
granted her a civil service disability annuity.
This case established two precedents. First, a federal appeals court recognized that ETS in
the workplace can prevent an otherwise normal and productive employee from performing
his or her job. Second, it recognized that such an employee, in effect, becomes disabled and
may be entitled to disability benefits.90
Workers Compensation Suits
In 1985, Marlene Richie, an administrative assistant in the Oregon State Executive
Department, won her claim against the state in a Workers Compensation hearing. The
ruling found that Ms. Richie had suffered a "bona fide occupational illness" because of ETS
in the department's central offices. The order rejected the state's assertions that no
compensation was due Ritchie because she was unusually sensitive to smoke and was a
"chronic complainer" about her health. "She has reason to be a chronic complainer about
her health owing to the fact that she actually is having health problems caused by
on-the-job cigarette smoke," the hearing referee wrote in his opinion. Her unusual
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sensitivity to smoke was not a valid argument against compensation, the referee held. "An
employer takes an employee as the employee is found," he concluded.91
In 1980, Helen McCarthy left her job with the Washington State Department of Social and
Health Services. After long-term exposure to ETS at work, she had developed chronic
obstructive lung disease, and filed for Workers Compensation. The state rejected her claim,
arguing that her disease was neither a work-related injury nor an occupational disease, the
two situations compensible under Workers Compensation. McCarthy then sued her
former employer for negligently failing to provide a safe and healthy workplace. The trial
court dismissed the case, stating that employers are immune from suits under Workers
Compensation. However, the Court of Appeals reversed that decision on the grounds that
since McCarthy's injury was not covered by Workers Compensation, preventing her from
suing her employer would unjustly deprive her of a remedy. The State of Washington
appealed the verdict and the case went to the state Supreme Court. The high court
unanimously confirmed the opinion of the Appeals court and again remanded the case to
the trial court. McCarthy and the State of Washington reached a settlement shortly before
the case was scheduled for trial.92
Unemployment Benefits
At least six states—New Jersey, Minnesota, Washington, California, Iowa and Idaho—have
granted unemployment benefits to nonsmokers who quit their jobs because they were
forced to work in smoke-filled offices.
SUITS BY SMOKERS
At the same time that some nonsmokers have found protection in the courts, several
lawsuits have indicated that smoking in public is not a legally protected right. In 1982,
Stanley and Elka Diefenthal, were denied seats in the smoking section of an airplane
because the section was already full. They sued the Civil Aeronautics Board, claiming their
right to smoke had been abridged. The trial court dismissed the case and the Diefenthals
appealed. The Court of Appeals refuted their claim, stating that smoking sections on
airplanes are created for the protection of nonsmokers, not the benefit of smokers.93
A few smokers have filed discrimination suits against employers who failed to hire them
because they smoked. In Tulsa, Oklahoma, firefighter Grusendorf filed suit against the City
when it prohibited smoking by firefighters on or off the job. He claimed the rule violated
his constitutional rights of liberty and privacy. The Court upheld the City rule, finding that
the fire department had a legitimate interest in the health of its employees.94
In a 1988 action, a job applicant in Minnesota claimed discrimination when an employer
refused to hire him because he smoked. The employer argued that the smoker was
undesirable because of his increased disability risk. The applicant appealed to the state
Human Rights Commission which ruled that the employer's refusal to hire could fall
within its definition of discrimination if it was based solely on concern about the
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employee's disability risk. Refusals are not discriminatory if the employer can prove that
the smoker's habit would impair his job performance or injure other employees. Because
the applicant's job involved working alone, the employer could not make either of those
claims. As a result, the Commission issued an executive order mandating that his
application be accepted.95
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CHAPTER 7: Developing Effective Smoking Policies
As concerns grow about the health effects of ETS, more organizations are implementing
smoking control policies. A 1988 study by the American Management Society Foundation
found that 60% of surveyed businesses had smoking policies in place and another 8% were
currently considering a policy. This was up from the 16% of businesses that had policies in
1980. In addition the survey found that 25% of the businesses surveyed prohibited smoking
at work. This was up from 14% in 1987.%
Organizations with
Formal Smoking Policies
60%
40
20
1980 1986 1987 1988
Q Have Official Policy
[2] Considering a Policy
Souto: AnwIcM MwgnMnt Soctoty Foundation Smoking Pollcto
Surray 1MO. !««, 1M7, 1MI. (dM In toornoH 1105)
Organizations implement policies to respond to employee complaints, to comply with local
legislation, to protect themselves from possible legal action and to reduce costs.
Organizations with successful policies find that they require careful thought and planning.
Who is involved in shaping the policy, how it is implemented, and the support given to
smokers are elements critical to its success. Failure to carefully consider these factors can
lead to policies that don't work. This chapter provides a brief overview of strategies for
developing and implementing successful smoking control policies.97
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A FIVE STEP PROCESS
Policy development and implementation is a five-step process. Attention to each step
should produce a policy that is fair, well-received and comprehensive. The five steps are
management review, situation analysis, strategic planning, implementation and
evaluation.
Management Review
Goal:
• to acquire information on the smoking issue and its impact on the organization and to
garner management support for developing a policy
To educate executive management on the smoking issue, information should be gathered
on the smoking issue and how it affects the organization. Include information on
employee complaints concerning smoking, the health effects of ETS, legal considerations,
and the financial implications of adopting or not adopting a policy. (A list of resources
appears at the end of this book.)
Situation Analysis
Goal:
• to gather background information on the organization's attitudes and needs in relation to
a smoking policy
Once management has decided to pursue a policy, it should select and charge a Policy
Development Team. This team will take primary responsibility for developing and
implementing the policy. It can be made up entirely of managers, or can be an
employee/management committee. It should include smokers, nonsmokers and
ex-smokers, and union representatives, whenever labor unions will be involved.
Smoking policies, like any change in working conditions, are often seen as a mandatory
subject of labor negotiation. Failure to include labor representatives in the policy
development and implementation process has lead to litigation. Some courts have sided
with unions, overturning the policy. Others have permitted policies to stand, citing the
overriding health and safety concerns.
The first task of the Policy Development Team will be to gather data about the
organization's needs and attitudes in relation to a smoking policy. Organizations often take
the following steps: conduct an employee survey to assess employees' attitudes toward
smoking in the workplace and toward possible restrictions; conduct a facilities survey to
examine the building's ventilation system (and areas that could be used as designated
smoking rooms), and review existing policies to see which might be affected by smoking
restrictions (e.g. break policies, hiring policies, discipline policies and employee benefits).
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Strategic Planning
Goal:
• to define the smoking policy
Where smoking is permitted is only one aspect of a policy. Many other considerations must
also be addressed:
- how will employees be educated about the policy?
- will stop-smoking classes be provided?
- will the company pay for the stop-smoking classes?
- how will the policy be enforced?
- how will policy violations be handled?
- will the new smoking policy impact hiring and break policies?
- will smoking be permitted in company vehicles?
- will it be permitted by visitors?
- will cigarette machines be allowed on company property?
- what will the signage needs be for the new policy?
In reviewing policy options, the Team should also talk to organizations and individuals
that have successfully implemented workplace smoking policies in order to learn from
their experiences.
Implementation
Goal:
• to implement the policy smoothly, with minimum disruption and maximum employee
support
Successful policies begin with carefully planned announcements. Explain the reasons for
the policy as well as its stipulations. Make sure employees understand that this is a health
and safety issue, not a crusade.
Announce the policy 90 days before it is to take effect. The 90 days between the policy's
announcement and its inauguration are critical. Use this time to educate employees and to
provide support to smokers. This will also give employees time to adjust and express their
concerns.
Organizations have successfully used employee newsletters, seminars, question and answer
sessions, telephone hotlines, and no-smoking signs to tell employees about the new rules,
about cessation programs, and about how to get more information. Present the policy as a
"win/win" effort. Don't pit smokers against nonsmokers. For the policy to succeed, it must
be seen as benefiting the whole organization, not one group. Top management should be
vocal in its support of the policy.
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Offer mechanisms for employees to comment on the policy. Train managers in responding
to the comments. Also make a special effort to listen to smokers. Get them involved in
creating designated smoking areas and planning cessation programs. Many smokers will
use the policy as an incentive to quit. Cessation programs help them with this goal and
promote acceptance of the policy.
Evaluation
Once the policy is implemented, the Policy Development Team, along with other
employees as needed, should conduct a comprehensive evaluation. The review should
review the following questions:
- how was the policy received by both smokers and nonsmokers?
- were there policy violations? If so, how were they handled?
- how was the employee education campaign received?
- how many employees enrolled in smoking cessation programs?
- how many employees quit smoking or reduced their smoking level?
- has the organization reviewed the cost containment possibilities created by the new
smoking policy?
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CHAPTER 8: Cost Savings Related to ETS Reduction
The Office of Smoking and Health in its 1990 Report to Congress reviewed the annual
financial impact of tobacco use and reported, "the total economic impact for all 50 States was
over $52 billion: $23.7 billion in direct morbidity (illness) costs, $10.2 billion in indirect
morbidity costs, and $18.5 billion in indirect mortality costs." The report concluded that
"with the sum of State economic costs exceeding $52 billion, the economic impact of
smoking can be put at some $221 per person each year. Thus cigarette smoking has an
economic impact on every American, whether or not he or she smokes."98
The exact contribution of ETS to the overall economic impact of smoking has not been
determined. There has been relatively little research in this area and most of the studies
that have been conducted only minimally document the direct and indirect costs of ETS.
Rather, the studies review the excess costs borne by companies as a result of having smokers
on the payroll. 99iooioiiQ2i03i04i05i06i07
A recent study of business executives asked if smoking increased costs for their companies.
69% of the executives surveyed felt that smoking increased medical and insurance
premiums, 44% felt that smoking increased maintenance costs, and 37% responded that
smoking increased absenteeism costs. 21 % of those surveyed responded that smoking had
no effect on their company's costs.108
Impact of Smoking on
Company Costs
1986
1987
1988
I Increased medical
Insurance premlumfe
65%
69%
69%
Increased
maintenance costs
38%
43%
44%
Increased
absenteeism
38%
45%
37%
Increased
accident*
11%
11%
7%
No effect on costs
25%
20%
21%
Sourca: American Society Foundation Smoking Policies Survey
1986, 1987, 1988. (cited In footnote *117)
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This chapter will summarize what is known about the costs attributed to ETS and about
possible cost savings as a result of ETS reduction. Much of the information in this chapter
is self-reported by organizations, or anecdotal. More research is needed to quantify if, and
where, cost savings are possible related to ETS.
DIRECT COST SAVINGS AS A RESULT OF ETS REDUCTION
When smoking takes place inside a facility, ETS can have a direct impact on the health and
productivity of nonsmokers and the maintenance of equipment and furnishings.
Nonsmoker Health and Productivity
Nonsmokers regularly exposed to ETS can experience a variety of impairments, from mild
irritation to cancer. At the low end, these impairments can reduce a worker's productivity
or cause absenteeism; at the high end, they can produce large medical or legal claims.
Pacific Northwest Bell prohibited smoking in its facilities in 1985 (its case study appears in
chapter 10). Following the implementation of its policy, the company documented savings
in health care costs. These included a 13% decrease in clinic visits for respiratory problems,
a 20% drop in respiratory- related absences lasting three days or more and a decrease in
clinic visits for headaches and sinus problems. Pacific Northwest Bell attributes a
substantial amount of these savings to the improvement in air quality based on its
smoke-free policy.
Maintenance and Repair
As discussed earlier, components of ETS adhere to indoor surfaces, which can cause them to
discolor and smell. As a result, costs for cleaning, repainting and replacing furnishings can
be higher when smoking is permitted. ETS can also damage sensitive equipment, such as
computers and laboratory equipment. Companies that fail to keep their equipment free of
ETS, therefore, can have higher equipment damage and depreciation costs.
Unigard Insurance prohibited smoking in its office areas and received a $500 monthly
discount in janitorial costs in one facility. Its cleaning vendor reported that there were
significant time savings due to not having to dump and clean ashtrays, reduced time
dusting desktops, reduced time spent edging and shampooing carpets, reduced maintenance
on upholstered furniture and a reduced window cleaning frequency.109 Pacific Northwest
Bell also reported a reduction in damage to office property, such as burns in rugs and
upholstery. The organization also found that overall cleanliness in its facilities improved.
INDIRECT COST SAVINGS AS A RESULT OF ETS MITIGATION
The Surgeon General's 1986 report observed that "a stringent smoking policy can decrease
the number of smokers within an organization." Companies that implement policies report
that this is the case. Pacific Northwest Bell found that following the introduction of its
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smoking policy, almost 25% of its smokers quit smoking and 61 % of the remaining smokers
report that they now smoke less. Reducing the number of smokers or eliminating smoking
entirely can result in lowered costs to a company in each of the following areas.
Fire and Accident Insurance
Organizations that prohibit smoking can bargain for lower fire and accident insurance
premiums. Research shows that smokers are more likely than nonsmokers to be involved
in fires110 and up to twice as likely as nonsmokers to be involved in accidents.111 As a result,
fire and accident insurance premiums where smokers are present can be higher.
Group Health and Disability Insurance; Productivity and Absenteeism
Insurance companies frequently offer discounts on individual health insurance policies to
nonsmokers. Similar discounts are now beginning to be offered to group policy holders as
well. Because implementation of a smoking policy in a business generally results in a
reduced number of smokers on the payroll, this can result in lower health insurance
premiums. King County Medical Blue Shield of Washington offers up to a 15% discount in
health insurance costs to organizations that prohibit smoking and have fewer than 10%
smoking employees. (They have also agreed to pay for 75 percent of the cost of smoking
cessation programs for subscribers.)
Discounts are also available in disability insurance premiums. Nonsmoker discounts range
from 3 to 14%, with the industry average at 8%. Some insurance providers impose a
surcharge on smokers. The average smoker surcharge varies from 10 to 14%, with the
industry average at 13%.
The effects of smoking on absenteeism have also been documented. Repeated studies have
shown a 33% to 45% greater absenteeism rate among smokers than nonsmokers.112 In 1979,
the Surgeon General reported that 81 million work days are lost per year due to smoking.113
This works out to approximately two days per smoker.
Studies show that smokers lose work time to the smoking ritual as well as to minor
smoking related impairments, such as reduced attentiveness. Estimates of productive time
lost vary from eight114 to 55115 minutes a day.
The 1986 Surgeon General's report stated that "it is generally agreed that employees who
smoke cost their employers more than nonsmoking employees because of excess
absenteeism, increased health care utilization, and reduced productivity. This leads to
greater use of sickness, disability and health care benefits and ultimately higher health
insurance costs to business."116
This was borne out in a study which compared health care utilization differences between
tobacco users and people who did not use tobacco in a large group insurance plan. The
study found that tobacco users had more hospital admissions (124 vs. 76), more total days in
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the hospital (800 vs. 381), a higher average length of stay (6.47 vs. 5.03 days), higher average
outpatient payments ($122 vs. $75), and a higher average of overall payments ($1145 vs.
$762). The authors of this study did observe tobacco use is correlated with other high risk
behaviors, therefore, cost and utilization differences may not be based solely on tobacco
The correlation between tobacco use and higher health care utilization and higher health
care costs was corroborated by a study at Pacific Bell, which found that the annual health
related costs (disability, absence, and health) of smokers averaged $593 more than the same
costs for nonsmokers.118
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CHAPTER 9: Public Attitudes Towards ETS
Surveys of public attitudes about smoking have been done since 1964. They have been
performed by major national polling organizations (the Roper Organization, Gallup Polls,
and Louis Harris and Associates) for the U.S. Office on Smoking and Health, the American
Lung Association, the American Cancer Society, the American Medical Association, the
Tobacco Institute, and other groups.
Regardless of sponsor, the polls show consistent results. They reflect increasing public
concern about the dangers of ETS, and increasing approval of restrictions on smoking in
public places and the workplace. These increases occur for both smokers and nonsmokers.
The Surgeon General's report observed that changes in attitudes about smoking in public
appear to have preceded legislation, but the interrelationship of smoking attitudes,
behavior and legislation are complex.
Public perceptions about risk and the degree of acceptance of restrictive measures has a
profound impact on the technical aspects of. mitigation strategies. Therefore a series of key
findings from public opinion polls are included.
The following chart summarize the results of some of these surveys.
Public Attitudes Toward ETS
What American Smokers and Nonsmokers Believe
100-
,
80-
,
60.
40.
20.
86%
77 %
69 %
s ;
ETS is
Harmful
Annoyed
by ETS
Smoker Should Not
Smoke Around
Nonsmokers
Source: American Lung Association / Gallup Survey 1989
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PARTffl
CASE STUDIES
The following chapters profile smoking policies in a variety of organizations and settings.
Each case study examines a policy's development, implementation and evaluation. All of
the policies described have been in effect for at least three years.
Across all the case studies, certain factors stand out as critical to a policy's success. These
include: demonstrated support for the policy by executive management, establishment of an
indoor or outdoor designated smoking area, development of a mechanism for gathering
employee feedback, implementation of a comprehensive employee education effort,
introduction of stop-smoking programs for smoking employees, participation of labor in
policy development and implementation, and development of a policy that applies equally
to all employees.
Chapter 1ft SMOKING POLICIES IN THE PRIVATE WORKPLACE
Pacific Northwest Bell (facilities in Washington, Oregon and Idaho) implemented a policy
prohibiting smoking in its facilities in 1985.
Honeywell Corporation (Minnesota) established separately ventilated designated smoking
rooms in its Minneapolis-area facilities in 1987.
Chapter 11: SMOKING POLICIES IN GOVERNMENT FACILITIES
The Indian Health Service (over 200 locations throughout the U.S.) in 1984 implemented a
policy prohibiting smoking in all of its facilities. The City of Bellevue (Washington)
established a separately ventilated smoking room in the Bellevue City Hall in 1985.
Chapter 12: SMOKING POLICIES IN HEALTH CARE FACILITIES
The Lexington Clinic (Kentucky), an outpatient clinic, prohibited smoking in its facilities in
1987. Swedish Hospital (Washington), a large urban hospital prohibited smoking in its
facilities in 1985.
Chapter 13: SMOKING POLICIES IN THE SCHOOLS
Andover Public Schools (Kansas) prohibited smoking in its facilities in 1978.
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CHAPTER 10: Smoking Policies in the Private Workplace
According to the Surgeon General, for adults living in a household where no one smokes,
the workplace is the greatest source of exposure to ETS.119 However, several concerns make
some private employers reluctant to institute smoking policies:
Angering Employees
Many managers fear that adopting a smoking policy will create dissension in the company
and cause employees to leave. However, studies of companies that have implemented
policies show that employees often favor the clarity that a smoking policy will provide and
that smoking employees generally lose their resentment within the first few months.
Enforcement
Many managers are concerned about having to punish smoking policy violators. However,
companies that have implemented policies report few cases of discipline involving
employees smoking at work. Smoking policies seem to be largely self-enforcing, with
employees reminding violators of the rules.
Labor Unions
Some companies assume that their unions will automatically oppose smoking restrictions.
However, many organizations find that when unions are involved in developing a policy,
they can be counted among the policy's supporters. Smoking policies are widely seen as a
subject of mandatory negotiation, so labor should be included in their development.
This chapter profiles two corporations that implemented different kinds of policies. Pacific
Northwest Bell prohibited smoking entirely. Honeywell established designated smoking
rooms in its corporate headquarters.
PACIFIC NORTHWEST BELL, SEATTLE, WASHINGTON
• Smoking Prohibition
BACKGROUND
Pacific Northwest Bell (PNB) is the telecommunications company serving Washington,
Oregon and Idaho. Now known by the name of its parent company, U.S. West
Communications, the company employs 15,000 people in over 750 separate buildings.
Among its facilities it counts business offices, substations, central switching offices,
computer centers, construction and vehicle garages, and its 32-floor headquarters building
in downtown Seattle. PNB employees include linemen, computer technicians, mobile
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service representatives, mechanics, operators and office personnel. This broad range of
facilities and employees all had to be accomodated in the company's smoking policy.
THE POLICY DEVELOPMENT PROCESS
PNB first began considering a smoking policy in 1983. The primary impetus was employee
complaints. The president, as well as health and safety officers, received frequent letters
from nonsmokers objecting to co-workers' tobacco smoke. Because of the growing
awareness of the dangers of ETS, the company was sensitive to these objections. Local clean
air legislation and press coverage also fed their concern for employee safety. To examine
the issue, management convened a Smoking Issues Steering Committee. Comprised of
company and union representatives, smokers, nonsmokers and ex-smokers, the committee
was charged with "exploring alternatives and recommending a policy that was fair and
equitable to all employees."120121 Over the next two-and-a-half years, the committee
gathered information and studied different approaches to limiting ETS in the workplace.
The committee began by surveying employees. Through an employee questionnaire, they
polled workers on their feelings about smoking on the job and at home, their smoking
status, and their grasp of the issue. The survey revealed that 26% of employees smoked
cigarettes (an additional 2% smoked pipes or cigars) and that employees harbored strong
dissatisfaction with existing smoking conditions. For example, 82% of nonsmokers
indicated they had occasionally been bothered by someone else's smoke. The survey results
reinforced the company's decision to develop a policy; in fact, PNB immediately reduced
the smoking area in all its cafeterias from 70% to 35%, better reflecting the proportion of
smokers. At the same time, they designated all their conference and training rooms
nonsmoking.
Next the committee reviewed the city, county and municipal ordinances regulating indoor
air in the three states in which they operate. The regulations varied. To meet them, the
company felt it needed a simple, but comprehensive policy. To generate some policy
alternatives, they reviewed the smoking policies of other corporations.
Then the committee turned its attention to company buildings. After conducting a facilities
survey, they found that existing ventilation systems were inadequate to meet the needs of
smoking areas. Retrofitting the systems would cost between $5,000 and $80,000 per room, a
prohibitive amount considering the large number of PNB buildings. That finding had a
strong effect on steering the company toward a smoking prohibition.
PNB knew that labor union support of its policy would be crucial. More than two-thirds of
the employees belong to either the Communications Workers of America or the Order of
Repeatermen and Toll Testboardmen. Without the unions' support, the company would
have had implementation and enforcement problems. To avoid these, they involved
union representatives in shaping the policy. The unions, representing both smokers and
nonsmokers, were in a difficult position. Taking a stand on either side would mean
potentially angering members. To avoid this, they each took a neutral stand on the policy.
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However, they had strong feelings about certain aspects of the policy that would affect all
their members, regardless of smoking status. They felt that in order to be fair, the policy
needed to be completely non-discriminatory: if one area was to be nonsmoking, all should
be. They also felt that if the company were going to require smokers to restrict their
smoking, management should pay for smoking cessation programs for employees, spouses
and dependents. As a result of the discussions, the company agreed to union requests, and
the unions agreed not to support grievances filed by individual employees.
As the committee gathered input and reviewed options, the company allowed individual
work groups to test their own solutions. Groups tried a variety of approaches. Some voted
on whether to permit smoking in their area: that left many workers feeling outvoted and
unhappy. Others permitted smoking only during certain hours: that failed when smoke
from a work group next door drifted into their area. Some decided to go smoke-free, but
unknowing smokers would walk through their area, arousing a hostile reaction. Others
asked smokers to cut back: that peeved smokers without satisfying nonsmokers. Every
alternative had drawbacks and the company continued to get complaints. As they weighed
the advantages and disadvantages of each, the scale tipped decisively in favor of a
facility-wide prohibition.
One week before announcing the policy, the committee presented it to employee focus
groups. The groups voiced the greatest concern about company commitment and
enforcement. As a result, a memorandum was issued to all directors, asking that they let
subordinates know that all officers—including PNB's president—were totally committed to
the ban. Then, on July 15, 1985, two-and-a-half years after the Steering Committee first
convened, a memorandum was sent to all employees. It said, "to protect the health of PNB
employees, there will be no smoking in any company facility." Three months later the
policy went into effect.
IMPLEMENTATION
Concurrent with the announcement of the ban, PNB began an employee education
program explaining the health effects of ETS and the reasons for the policy. The effort
included the company newsletter, its in-house health and safety magazine and a telephone
"hotline" employees could call with questions or comments.
At the same time the company agreed to reimburse employees, spouses and dependents
who attended a cessation program from an approved list. Individuals were free to choose
the type of program that would work best for them, a choice which appeared to increase
their commitment to succeed. As a result of the program, 1,541 employees signed up for
classes. Forty percent were still not smoking after a year, and the percentage of smoking
employees dropped from 28% to 20%. In a recent survey evaluating the prevalence of
cigarette smoking, 66% of smoking respondents said it had helped them cut down or quit.
The average smoker had smoked more than 20 years before entering the program, and had
tried to quit approximately five times. The majority of ex-smokers say they feel healthier
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since they stopped smoking and that the work environment has improved since policy
implementation.
EVALUATION
According to a company spokesman, the smoking policy is "one of the most successful
policies PNB has ever implemented." Enforcement has not been a problem: only one
employee violated the policy and received a verbal warning, as part of PNB's normal
progressive discipline program (verbal warning, written warning, suspension and
termination). Today headquarters employees, who work in one of the taller buildings in
Seattle, are well-known for having to go down as many as 32 flights and out the door when
they want a cigarette.
PNB recently completed a follow-up study on its smoking policy. They conducted a random
sample of 1800 employees with a survey response rate of 89%. The employees were asked
how they felt about the ban on smoking inside company facilities. Seventy percent
responded that the policy was "about right", 18% said the policy was "not strict enough",
and 12% reported that the policy was "too strict". The company reports that 60% of the
current smokers agreed that the ban on smoking in company facilities was "about right".
The company also asked employees about the harmfulness of ETS. Ninety-one percent of
the employees called ETS "definitely or probably harmful", 3% called it "definitely or
probably not harmful", and 6% responded that they "don't know or are not sure".
PNB knew that implementing a policy would cost money, but decided early on that they
would rather "invest" that money in employee health than pay the on-going expense of
permitting smoking. After implementing the policy, they systematically measured its
financial impact, and found that it produced substantial cost savings: there are now 13%
fewer visits to company clinics for respiratory problems; there has been a 20% drop in
respiratory-related absences lasting three days or more (this equals a cost savings for
incidental and disability absences of $111,000) and visits to clinics for headaches and sinus
problems are down. Savings on health insurance are difficult to measure because of the
large number of contributing factors, but based on these statistics the company believes
them to be substantial. In addition, damage to office property, such as burns in rugs and
upholstery, has decreased, and overall cleanliness has improved.
Offsetting these savings, PNB spent an average of $145 per smoker—less than $250,000—on
cessation classes. They contrast this with the much greater sum it would have cost to
re-ventilate their 750 buildings, and feel they made a wise economic choice to implement a
smoking prohibition.
In fact, they could have reduced their cessation costs further. In their eagerness to provide
customized classes, they offered a wide array of programs. Some (hypnosis and
acupuncture) were less effective than others (group and individual support sessions, and
doctor-prescribed programs). Had the company limited the cessation options, they might
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have steered employees to more effective programs and negotiated discounts with program
suppliers.
In evaluating its policy, PNB emphasizes the following points:
PNB's significant employee and union involvement in shaping the policy played a key role
in gaining employee support for the policy.
The comprehensive and free smoking cessation program for employees, spouses and
dependents played an important role in getting smokers' support for the policy.
HONEYWELL CORPORATION
• Separately ventilated smoking rooms
BACKGROUND
Honeywell Inc., manufacturer of electronics equipment, employs 56,000 people in its 22 U.S.
divisions. The company owns or leases over 400 buildings, including its large corporate
headquarters in Minneapolis, branch offices around the country, and several major
manufacturing plants. Approximately 40% of its facilities are in the Minneapolis area.
THE POLICY DEVELOPMENT PROCESS
Honeywell first developed a smoking policy in response to Minnesota's new Clean Indoor
Air Act. The company asked its divisions nationwide to implement policies regulating
smoking. They were to follow the guidelines of the Act and create, at a minimum,
designated smoking areas. In response, some set up smoking lounges; others permitted
smoking everywhere except in designated no-smoking areas. Most company cafeterias were
divided into smoking and no-smoking sections. The company did not recommend
enforcement provisions, and therefore, few divisions had them.
However, as information about ETS grew, employee complaints persisted. Many people
worked in open offices in which smoking and nonsmoking sections were side by side.
Others worked in nonsmoking areas that adjoined closed smoking rooms from which some
smoke escaped. In response to employee concerns divisions gradually tightened their
policies.
An employee survey was conducted through Honeywell's in-house publication. It asked if
employees favored increased smoking restrictions and 75% said they favored the same level
or greater restrictions. This resulted in a policy to move closer to a smoke free
environment. Smoking was banned from conference rooms, offices and common areas.
This approach resulted in both positive and negative feedback from employees and
management. It was decided that the Minneapolis-area operation would develop a
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uniform policy for their facilities. Out-of-town divisions were asked to develop and refine
their own policies to best meet their needs.
The task of developing the Minneapolis-area policy was given to the Human Resources
directors of those divisions. This group met for almost a year, talking with union
representatives and examining policy options. Finally, the committee decided on a policy
that would ban smoking from Honeywell buildings and grounds.
IMPLEMENTATION
To ease the transition for smokers, management decided to implement the policy gradually.
Three to four months before the policy was to take effect, it was announced in the company
newsletter. Also announced was a "phase-in" period during which the policy would be in
effect but would carry no penalties. Several months later, in response to considerable
employee concern, the company rescinded the total ban, and created "temporary" smoking
rooms in each building while they re-exmained the policy. Free on-site smoking cessation
programs were already being offered both on and off hours.
After several more months of deliberations, a revised policy was issued for Minneapolis
operations. Honeywell decided to retain the designated smoking rooms as a reasonable
accommodation for all concerned. This time violation penalties were specified;
enforcement would be handled by department managers; penalties would follow usual
disciplinary procedures including reprimands, demerits, verbal and written warnings, and
possible termination.
To accomodate the large amounts of smoke, ventilation in the smoking rooms was
modified. Each room was vented directly to the outside; exhaust fans and air cleaners were
added. The cost of the changes in ventilation was estimated to be a few thousand dollars
per room.
EVALUATION
The new policy is considered successful. 99% of employee smoking occurs in the smoking
rooms, with smokers occasionally reminded by co-workers not to smoke elsewhere. Most
infractions occur on weekends or evenings when the offices are largely empty.
Nonsmokers occasionally complain that smokers get extra break time, but most of the early
discomfort with the policy has quieted down.
The smoking lounges seem to meet the needs of smokers, although they generate
occasional complaints from nonsmokers. When large numbers of smokers are present,
smoke escapes from some of the rooms through the doorway. Workers in adjacent offices
have complained, and in the corporate headquarters building, extra doors were added to
one smoking room to minimize such leaks.
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Today, Honeywell feels it has learned valuable lessons in policy development, and is
pleased to have a smoking policy it considers successful. Many of the out-of-town divisions
also have implemented a policy in keeping with their local needs and environment.
In evaluating its policy, Honeywell emphasizes the following points:
Honeywell could have paid closer attention to the needs of smokers.
It should have demonstrated strong management commitment to the policy from the start.
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CHAPTER 11: Smoking Policies in Government Facilities
The 16 million Americans employed by federal, state and local governments are subject to
widely different smoking regulations. While some government agencies prohibit smoking
entirely, many restrict it to designated areas and some have no regulations at all. Increasing
numbers of agencies are implementing or making smoking policies more stringent.
However, some agencies hesitate to tackle the issue because of the following concerns:
Occupational Variety
Within one government agency, the range of occupations — and work environments — can
be huge. A small city government, for example, may include offices, hospitals, vehicles,
waste facilities, fire stations, public transportation facilities, an airport, and other disparate
sites. Developing a policy that meets the needs of each site can seem formidable. However,
governments have found that when a policy is developed with input from everyone
affected, it can be implemented smoothly and successfully.
Labor Unions
Labor contracts in government can have weaker management rights sections than those in
private business. This can weaken management's position in negotiating a policy.
Government agencies have avoided this problem by bringing unions into the policy
development process early on as a partner.
Layered Decision-Making
Government agencies tend to have slow, layered decision-making processes that can
hamper the development and implementation of new policies. Governments have
streamlined this process by treating smoking policies not as political issues, but as internal
personnel issues.
This chapter profiles the policy development process in two government organizations.
The Indian Health Service prohibits smoking in all of its facilities. The City of Bellevue
created an enclosed, separately-ventilated, designated smoking room.
INDIAN HEALTH SERVICED
• Smoking Prohibition
BACKGROUND
The Indian Health Service (IHS) is the primary health care provider for approximately one
million Native Americans. Its facilities include 11 area offices, 43 hospitals, 66 health
centers, and over 100 health stations and satellite clinics throughout the United States.
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•PLEASE RETURN TO:
NCIC/OTS CHEMICAL LIBRARY
401 M ST., S.W., TS-793
WASHINGTON, D.C. 20460
THE POLICY DEVELOPMENT PROCESS
In 1983, IHS doctors and administrators began to consider restricting smoking. Their reason
was simple: they wanted to reduce the number of Indians who smoke. They were
supported in this goal by Indian tribal leaders as well as by Surgeon General Koop who
helped them map a strategy. Together they developed the goal of a Smoke Free IHS.
To develop the policy, they formed a Smoke-Free Task Force. The 18 member committee
included administrators, doctors and nurses; Indians and non-Indians; smokers,
nonsmokers and ex-smokers. The Indian representatives were adamant: they would
support a policy only if it were equitable, that is, if it applied equally to Indians and
non-Indians. That meant administrators, doctors, nurses, janitors, food service workers,
patients... everyone working in or using the facilities would have to be equally restricted.
There could be no smoking in private offices, in conference rooms, or in any other areas
off-limit to Indian patients. In effect, the Indian representatives would support only a total
prohibition of smoking in IHS facilities.
80 to 90% of the clinical care providers of IHS welcomed this as good news. They too
favored a ban. IHS leadership; administrators, physicians, nurses, pharmacists, etc., had
long recognized the great importance of disease prevention, if the limited annual budget
were to make inroads against the extensive health problems of Native Americans.
Smoking control was essential in disease prevention.
Unlike some other hospital systems where nurses, many of whom smoked, had been
reported as a group to tend to offer resistance to smoking control, the Native American
Nurses Association was one of the first groups to offer support for a total smoking ban. IHS
encouraged this nursing leadership by giving early key roles in the policy planning and
development to nurses and saw to it that later recognition and credit was given to the
nurses.
IMPLEMENTATION
The task force decided that implementation would be handled autonomously by individual
IHS facilities. As a result, implementation was uneven. Some facilities implemented the
ban immediately. Others phased it in over two years, first restricting smoking to a few
areas, eventually banning it altogether. In some facilities, staff and patients were
extensively educated through memos, newsletters and presentations at which employees
could ask questions and voice concerns. In others, education was left to the announcement
memo and signage. Implementation was delayed the longest in a handful of the 200
facilities where there were weaker education programs and where staff felt their concerns
were not addressed.
In contrast with the strong general support from clinicians, the non-clinical care employees,
such as laboratory and maintenance equipment/store room employees tended to be less
appreciative of preventive health measures and were less supportive as a group. Most local
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community union members were supportive. Of the 19 unions representing IHS
employees in 25 states, 17 were involved in the early discussions for planning,
development and implementation of the new smoking control policies. However, in two
instances where local hospital administrators did not follow IHS leadership instruction for
proper involvement of the unions, there was a challenge by local unions.
In one of these instances (Tahlequah, Oklahoma) a union grievance was taken through
Federal Court to the U.S. Federal Labor Relations Authority, September 1986. This was one
year after the hospital and the IHS had already successfully implemented their smoking
bans at 200 facilities in 25 states on a system-wide basis.
The Federal Judge's ruling dated July 23,1987 dismissed the union grievance as without
validity. However, an appeal by the union has resulted in a 1990 reversal of the 1987 ruling
to say that the IHS local facility at Talhequah, Oklahoma was in error in not negotiating
with the union before implementing the smoking ban as a "fait accompi." In response to
this ruling, the Department of Health and Human Services of the U.S. Government, as the
department responsible for the Indian Health Service, has pointed out that IHS failure to
properly negotiate in advance with the union at the one facility mentioned is of no current
relevance at this time since the U.S. Government General Service Administration (GSA)
smoking policy has since been updated to allow total smoking bans at the discretion of the
U.S. Government Agency Heads. The U.S. Department of Health and Human Services has
established total smoking prohibitions at all of its facilities, including the IHS.136
In most facilities, IHS gave employees time off to attend smoking cessation programs and ,
offered nicotine gum to those who wanted it. The labor unions also made these available to '
their members.
EVALUATION
Overall, IHS feels reaction to the ban was positive. The majority of complaints came from
smoking staff members and these subsided after the first several months. Few patients
complained, and compliance to the prohibition has been good. In evaluating its policy, the
Indian Health Service emphasizes the following points:
Iln addition to strong top leadership, there must be significant early employee and staff
participation and involvement. In some facilities, IHS could have done a better job of
involving the unions in developing and communicating the policy to employees.
The strong support of employees and the fact that the policy applied equally to all was the
key to the success of the policy.
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CITY OF BELLEVUE, WASHINGTON
• Separately ventilated smoking room
BACKGROUND
Bellevue, with a population of 85,000, lies just across Lake Washington from Seattle. A
suburb in the 1960s, it has since become the fourth largest city in the state, boasting branches
of many national corporations and a burgeoning downtown skyline. Bellevue's 11
government departments are headquartered in City Hall. Other facilities include sewage
treatment plants, mechanical bams, maintenance sheds, parks, a community college, fire
stations, other buildings and vehicles. Five unions represent a third of the city's 900
employee workforce.
THE POLICY DEVELOPMENT PROCESS
By 1985 Bellevue already had developed a simple and successful smoking policy for city
vehicles: nonsmokers prevail. But that year, a group of nonsmoking employees in City
Hall complained about tobacco smoke at their desks. They took their grievance to the
Employee Committee, a standing committee of elected and appointed employee
representatives charged with handling personnel matters, and the Committee created a
Smoking Policy Committee, made up of smokers, nonsmokers and ex-smokers to explore
the issue.
The Committee knew that its policy would have to work in every city facility, and in
unionized departments with different working conditions. To smooth the process, they
invited representatives from the five unions to work with them. They researched the
health effects of ETS, discussed policy options, and outlined a strategy. The first step was an
employee survey to document smoking preferences and attitudes. The survey revealed that
only 19% of employees smoked, that over 70% felt tobacco smoke was a problem, and
suggested that the workforce would more strongly support designated smoking rooms than
a ban.
Concurrent with the survey, presentations were scheduled for all employees. The
presentation explained that the City was considering a policy, explained the reasons why,
covered the health effects of ETS, and solicited reactions from the employees. Smokers and
nonsmokers were able to air their concerns as well as ideas for solutions. The presentations
were instrumental in developing support for the policy because all sides felt their views
were heard.
Since employee opinion strongly favored designated smoking rooms, the City examined
that option with a ventilation engineer. Fortuitously, at that time, the City Hall lobby was
being renovated, and for under $5,000 the City of Bellevue created a smoking lounge with
separate ventilation in the City Hall. This would satisfy City Hall employees.
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A smaller number of employees worked outside City Hall. These workers (police,
firefighters, sanitation workers, utilities workers, mechanics, etc.) had greater mobility than
those in City Hall, and agreed that separate smoking rooms were unnecessary: they could
easily smoke outside.
With that decision the policy was determined: smoking would be prohibited except in
designated smoking areas. In buildings with no designated area, smoking would be
restricted to outside.
IMPLEMENTATION
Three months before it was to begin, the City announced the policy with employee
newsletters and bulletins. They explained the role of employee input in shaping the policy
and invited comment. Concurrently, they offered free smoking cessation classes to all who
wanted them. Approximately a third of the smokers participated, and many of those quit
smoking. Because the City Hall smoking lounge was not ready when the policy took effect,
the City temporarily designated a portion of the lunch room as a smoking area; a few
months later, the permanent lounge was opened.
Shortly after the policy was announced, the attorney for the Police Guild argued that it
represented an unfair change in working conditions. But Guild leadership, satisfied with
the policy, refused to make an issue of it.
EVALUATION
Overall, reaction to the policy was good. Some employees complained in the first few
months, but grievances gradually tapered off and stopped. City managers had been
concerned that unhappy smokers would defy the policy by smoking in secret, but only one
employee did so. Despite "no smoking" signs, visitors occasionally light up in the building,
but always stop smoking when asked. A second City concern, that smokers taking breaks in
the lounge would suffer a decline in productivity, did not materialize.
In evaluating its policy, the City of Bellevue emphasizes the following points:
The City of Bellevue's maximized employee participation in policy development.
The City established an adequately-ventilated, designated smoking room.
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CHAPTER 12: Smoking Policies in Health Care Facilities
The reasons to establish smoking policies in health care facilities are clear: patients are
particularly susceptible to injury from ETS, and, surrounded by flammable materials,
patients smoking in bed are a safety risk to themselves and others (the American Hospital
Association has stated that 66% of all hospital fires are caused by smoking). Many health
care facilities have successfully implemented policies. However, some hesitate to do so
because of the following concerns:
Patients Who Smoke
Nicotine is addictive, just like heroin or cocaine. Patients who smoke may not be able to
stop, regardless of their health. Many hospitals have alleviated this problem by prescribing
nicotine gum to addicted patients during the hospital stay.
Nurses
While the smoking rate among physicians is significantly lower than that of the general
population, the rate among nurses is not. This means that many hospitals employ large
numbers of nurses who smoke. At a time when health care facilities face a nursing
shortage, many are reluctant to do anything that might alienate nurses or impair their
recruitment. However, hospitals that have implemented policies report that few nurses
leave because of the smoking policy. Including nurses in policy formulation is regarded by
many hospitals as a key factor in the overall success of the policy. When included in the
process nurses are often strong supporters of smoking policies.
Marketing
Hospitals today are increasingly competitive as they fight for market share, many like to
avoid policies that may potentially alienate customers. Smokers are among their best
customers, for while they are a minority of the population, they have higher rates of
hospitalization. Hospitals with policies, however, report no decline in admissions.
The following case studies explain how two health care facilities addressed the smoking
issue. The Lexington Clinic prohibited smoking in its facilities. Swedish Hospital also
prohibited smoking in its facilities.
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THE LEXINGTON CLINIC
• Smoking Prohibition
BACKGROUND
The Lexington Clinic is a 100-physician, multi-specialty group practice clinic. Its 11 buildings
are scattered throughout Lexington, Kentucky, where the Clinic has been operating for 70
years. It has no overnight facilities; patients requiring hospitalization are referred to local
hospitals. However, some patients stay at the Clinic for several hours for extended
procedures. The Clinic is owned by its physicians, and operated by an elected physician
Board of Directors and an administrative staff. It has 650 employees, and is not unionized.
The Clinic is located in a region that many consider the burley capital of the world. Many of
its patients are tobacco farmers and their families, and tobacco forms the backbone of the
local economy. Clinic staff was concerned that introducing a smoking policy would
potentially anger Clinic patients and supporters.
THE POLICY DEVELOPMENT PROCESS
The idea of a smoking policy was first raised in 1982. Staff, concerned about the dangers of
ETS, urged management to restrict smoking. They felt that despite the community's
reliance on tobacco, the Clinic should set a health standard for its patients by eliminating
ETS. Management asked the Clinic's Safety Committee to study the issue.
The Safety Committee was a management committee whose members included both health
care and non-health care professionals. After weighing both sides of the ETS
issue—community concerns vs. the health of their patients—they recommended a policy
restricting smoking to designated lobby areas, private offices and employee lounges. They
felt that was consistent with what other organizations were doing about ETS, and that it
would not upset the community.
But as new information surfaced about the dangers of passive smoking, staff concerns
continued to grow. In late 1986, following publication of the Surgeon General's report,
Clinic administrators asked the Safety Committee to re-examine the smoking issue. Their
mandate was to research information on ETS and recommend a course of action.
The Safety Committee spent several months gathering information. They reviewed
medical literature on the health effects of ETS, examined ventilation options, and consulted
experts in the field. Finally, convinced that ETS had to be eliminated from the facilities and
that proper ventilation for smoking rooms would be prohibitively expensive, the
Commiltee recommended that smoking be banned inside Lexington Clinic facilities.
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IMPLEMENTATION
Clinic administrators announced the policy in March, 1987 and scheduled it to begin on July
4th. They also appointed an employee committee of smokers, nonsmokers and ex-smokers
to help plan its implementation, and a management committee to develop the programs
and strategies recommended by the employee committee.
The committees' roles were to educate employees, physicians and patients about the policy,
and to act as conduits for employee feedback and concerns. Using material gathered by the
Safety Committee, they developed a memo explaining the health risks of ETS, the Clinic's
lack of ventilation options, and the rationale for the decision to prohibit smoking. It
stressed that the policy was a health initiative, not a moral crusade, and reminded people
that they were free to smoke outside during employee breaks. The Committee also arranged
for the Clinic to offer free smoking cessation, weight loss, and stress reduction classes to
employees and their spouses.
During this period, feelings about the ban were divided. One group of physicians and
employees, including both smokers and nonsmokers, supported it. They felt that as a health
care facility, the Clinic had no choice but to ban a substance that could harm their patients.
On the other side were smokers and nonsmokers who felt the ban would insult their many
tobacco farming patients.
As July 4th crept closer, a small group of physicians and employees remained actively
opposed. To address their concerns a presentation was scheduled for the Clinic's 100
physicians.
At the meeting all sides were given a chance to voice their concerns. In addition, the
physicians were presented the most recent medical research, the current status of litigation
and legislation, public opinion surveys, trends in smoking policies in health care facilities
and other organizations, and the costs associated with permitting smoking. At the end of
the presentation, an influential physican stood up. "I am a smoker," he said, "and until
now I have been opposed to this ban. But in light of this information, I am changing my
mind. As owners of this organization, we have a responsibility, we cannot allow smoking
in our buildings." The group of physicians voted for the prohibition.
Two weeks later the policy went into effect. The Clinic built covered smoking shelters
outside to protect smokers from weather and to show smokers they were aware of their
needs. They kept cigarette vending machines in the buildings to remind smokers that they
were not forcing them to quit, merely restricting when and where they smoke.
EVALUATION
To everyone's surprise, the ban was widely accepted from the first. According to the policy,
employee enforcement is handled as it is for any Clinic policy: violators receive verbal
counseling, written counseling and finally dismissal if they fail to comply. However, these
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penalties have never been necessary. The occasional infractions, which are generally from
patients and not staff, are curtailed with verbal reminders.
Community reaction was also positive. The local media gave the policy positive coverage.
Daily visits held constant at 1,400. And while the Clinic had braced for a strong reaction
from tobacco farmers, they received only two letters of complaint.
In evaluating its policy, the Lexington Clinic emphasizes the following points:
The Lexington Clinic's implementation of an aggressive communication and education
effort during the three-and-a-half month adjustment period.
The establishment of an outdoor, covered smoking area.
SWEDISH HOSPITAL, SEATTLE, WASHINGTON
• Smoking Prohibition
BACKGROUND
Swedish Hospital, with 600 beds, is the largest hospital in the Northwest. It has a medical
staff of 1,000 and occupies a dozen buildings near downtown Seattle.
THE POLICY DEVELOPMENT PROCESS
The policy development and implementation process occured in three stages over two
years. It began in 1985 when the hospital's executive director, Dr. Alan Lobb, convened a
Smoking Policy Committee to study the smoking issue. Lobb felt strongly about the dangers
of smoking and asked the Committee, which included smoking and nonsmoking
managers, to determine how the hospital could limit ETS in its facilities.
While the Committee knew that Lobb's preference was to prohibit smoking, they felt that
introducing restrictions gradually would be a better way to proceed. As a first step, they
created a number of no smoking areas: most of the cafeteria was made "smoke-free," and
each department was asked to decide if it wanted smoking in its employee lounge.
Smoking was still permitted by patients in their rooms.
The decision to allow each department to establish its own policy proved difficult, however,
as department managers became caught between smokers' and nonsmokers' competing
demands. Finally staff asked the Committee to create a hospital-wide policy. A year after
the first policy was introduced, the Committee revised it to prohibit smoking by employees
and visitors everywhere in the building. Only patients were permitted to smoke in their
rooms.
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Before the new policy took effect, employees objected, requesting one place in the building
where smoking would be allowed. The hospital complied, and established a separately
ventilated smoking room in the cafeteria. When the concentration of smoke in the small
area proved too much for the ventilation system, new exhaust fans were added. Even with
the new fans, the air filters had to be changed twice a week and the room's walls discolored.
After six months the medical staff of the hospital, wanting to set an example in the
community, asked Dr. Lobb to recommend a complete prohibition. With the full support of
the CEO and the medical staff, the Committee then announced that Swedish would be a
smoke-free hospital. The only exception would be occasional patients who would be
permitted to smoke with their doctor's agreement.
IMPLEMENTATION
Before the policy was to go into effect, memos were sent to all employees informing them of
the ban and the reasons behind it. They also offered free cessation classes to all who wanted
them. A relatively small number signed up, and some employees quit smoking.
Knowing it was important to reach patients before they arrived, the hospital made strong
efforts in patient education. They printed "tent cards" explaining the policy and distributed
them to all physicians who refer patients to Swedish, and added information about the
policy to their pre-admission packets.
EVALUATION
The policy met with little resistance. The hospital received complaints from patients who
argued that they had removed their only solace during sickness. The hospital answered
with an explanation of the health benefits of the policy.
Compliance with the policy has been good. Enforcement is done by physicians rather than
nurses. If a patient insists on smoking, his or her physician will decide whether or not the
smoking should be allowed. To smoke, the patient must be in a private room, and the
circumstances must be exceptional.
Concerns that smoking patients would take their business elsewhere have not been
realized. Swedish has seen no decline in admissions since going smoke-free.
In evaluating its policy, Swedish Hospital emphasizes the following points:
The support of the leadership of Swedish Hospital was the key to the successful
implementation of the new smoking policy.
The hospital made a strong commitment to educate patients about the policy before they are
admitted to the hospital.
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CHAPTER 13: Smoking Policies in Schools
Thirty-two states restrict or prohibit smoking by students.123 Nearly as many restrict
smoking by faculty to "adults only" areas. These areas are frequently under-ventilated,
however, and smoke seeps easily to areas where children are present. According to the
Surgeon General, "a total prohibition of smoking on school grounds provides the greatest
protection from sidestream smoke exposure and unwanted role modeling effects."1?* Yet
many schools are hesitant to impose such a ban for the following reasons:
Fear of Angering Teachers
Teachers are under tremendous pressure. Administrators are reluctant to add to the
pressure with a potentially "unpopular" restriction. However, studies of other worksites
show that smoking bans are popular with the majority of employees, and that smokers
adjust to the ban within several months.
Enforcement
Like administrators in any worksite, school principals are not eager to create policies which
contain potential discipline problems.
This chapter profiles the Andover Unified School District #385, which prohibited smoking
for teachers as well as students. Its success led to smoke-free schools throughout the state of
Kansas.
ANDOVER, KANSAS PUBLIC SCHOOLS
• Smoking Prohibition
BACKGROUND
With 3,600 people, Andover, Kansas might qualify as a small town—except that it is a
suburb of Wichita. In the 1970's, Andover's quiet life, ample space, and small school district
began attracting families from the city. By 1978 the district had grown to 1,200 students. It
had one high school which permitted smoking in the building for teachers but prohibited it
for students.
THE POLICY DEVELOPMENT PROCESS
By 1978, smoking in the high school had become a source of tension. Students were
slipping out to smoke between classes, and at lunchtime the lawn was filled with students
lighting up. Teachers were reprimanding students who took cigarettes out in school, and
parents were concerned about their children's health. To ease the problem, school board
members suggested prohibiting student smoking on school grounds as well as in the
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buildings. However, other school board members objected that prohibiting smoking for
students—while letting teachers smoke—was hypocritical and unfair. They advocated
prohibiting smoking in the Andover School District for teachers as well as the students. No
school district they knew of had prohibited smoking for teachers, but as the school board
examined its options, it seemed like the best one.
Knowing that a prohibition might meet resistance in the community, the school board
gathered ammunition. First, they polled students and teachers to find out how many
smoked: the number was small. Next, they examined their insurance coverage and
discovered that prohibiting smoking on school grounds would drop their property
insurance premium significantly. This was a compelling argument for a fiscally
conservative school board, and one they expected would be equally powerful for the
community, which was currently seeking funds for a new gymnasium. The board took this
information to the next public school board meeting.
To their surprise, the prohibition idea met little resistance. Parents embraced it, thankful to
have help from the school in curbing their children's smoking. Most teachers cheered it,
because they favored further tobacco restrictions for students, because they hoped it would
reduce the tensions over smoking, or because they were eager to rid the school of ETS.
Only a small group of teachers protested, claiming the school board was abridging their right
to smoke, and overstepping its role as administrators.
The board discussed the issue at five public school board meetings before deciding to pass
the prohibition. Ultimately they felt the writing was on the wall. The strong feelings of the
community and the nation's growing intolerance for smoking suggested that if they didn't
prohibit smoking themselves, the state would eventually make them do it. One school
board member said, "if you wait until the state makes you do it, you've waited too long."
IMPLEMENTATION
The board announced the prohibition in August with a one-paragraph memo. It stated that
beginning the following September, smoking would be prohibited for students and teachers
in school buildings and on school grounds. Although some teachers had objected strongly
to the prohibition while it was under discussion, complaints died down once the policy was
on the books. Those who still wanted to smoke drove down the street. Most refrained
from smoking during school hours. In an unexpected side benefit, the district found that
without cigarettes, teachers spent less time in the faculty lounge and more time with
students in hallways, schoolyards, and lunchrooms.
Enforcing the prohibition among students has been easier than enforcing the earlier policy,
in part because it has eliminated the problem of students lighting up "on their way
outside." According to school representatives, discipline problems are "nothing compared
to what they were."
PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 61
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EVALUATION
In the community, the prohibition was widely supported. Parents were delighted to see the
school curb smoking. The large majority of teachers approved. Even people with no
connection to the schools supported the decision to protect the health of students. The local
newspaper published an editorial praising the school board for its decision.
In evaluating its policy, the Andover School District emphasizes the following points:
The Andover School District worked to gain extensive public support for its effort to
eliminate smoking from environments with children.
The policy was fair because it placed the same rules on teachers and students.
AFTERMATH
Nine years after Andover implemented its smoking prohibition, the state of Kansas
prohibited smoking in public schools statewide. Several other school districts had followed
Andover's lead, and hoping to spread the policy to the rest of the state, the Governor asked
a state representative to introduce a bill in the legislature.
The debate in the legislature was partisan, divided by political party and smoking
persuasion. Proponents argued that the bill was necessary to protect the health of children;
opponents argued that smokers' rights were being taken away. However, the opponents
were outnumbered, and in 1987, Kansas became the first state to prohibit smoking in
schools for teachers as well as students. Public response was overwhelmingly positive.
62 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE
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RESOURCES
For additional information on ETS, contact your state or local health department, or the
following:
Indoor Air Division (ANR-445)
Office of Air and Radiation
U.S. Environmental Protection Agency
401 M Street SW
Washington, D.C. 20460
Office on Smoking and Health
U.S. Public Health Service
5600 Fishers Lane, Room 1-10
Rockville, Maryland 20857
Office of Cancer Communications
National Cancer Institute
1-800-4-CANCER
American Cancer Society
4 West 35th Street
New York, New York 10001
American Lung Association
1740 Broadway
New York, New York 10019
American Heart Association
7320 Greenville Avenue
Dallas, Texas 75231
Public Relations Office
American Society of Heating, Refrigeration
and Air Conditioning Engineers (ASHRAE)
1791 Tullie Circle, NE
Atlanta, Georgia 30329
PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 63
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Cigarette smoke is only one of many indoor air pollutants that can affect your health and
comfort. Other EPA publications concerning the quality of indoor air include:
* The Inside Story: A Guide to Indoor Air Quality
* Directory of State Indoor Air Contacts
* Indoor Air Facts #3: Ventilation and Air Quality in Offices
* Indoor Air Facts #4: Sick Buildings
* Indoor Air Facts #5: Environmental Tobacco Smoke
* Indoor Air Facts #6: Report to Congress on Indoor Air Quality
* Indoor Air Facts #7: Residential Air Cleaners
These publications, as well as additional copies of this publication, are available from:
Public Information Center
U.S. Environmental Protection Agency
Mail Code PM-21 IB
401 M Street SW
Washington, D.C. 20460
The National Cancer Institute has developed a series of one-page information sheets on all
aspects of smoking in the workplace. These question and answer sheets were produced by
the Office of Cancer Communications. For copies call 1-800-4-CANCER.
* The Health Effects of Environmental Tobacco Smoke
* Implementation of Smoking Policies
* Strategies for Selecting Smoking Cessation Programs
* Costs and Benefits of Smoking Restrictions in the Workplace
* Smoking in the Workplace: Ventilation
* Smoking in the Workplace: Legal Issues
* Smoking Policies and the Unions
* Smoking Policies in Health Care Institutions
* Smoking and the Female Work Force
* Smoking and the Blue-Collar Work Force
64 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE
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FOOTNOTES
1. US. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989.
DHHS Publication No. (CDC) 89-8411. p. 12.
2. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Smoking and Health, A
National Status Report. 1990. DHHS Publication No. (CDC) 87-8396 (Revised 2/90). p. 8.
3. U.S. ENVIRONMENTAL PROTECTION AGENCY, Health Effects of Passive Smoking:
Assessment of Lung Cancer in Adults and Respiratory Disorders in Children. 1990. p.
4. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989. op.
dtp. 11.
5. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Smoking and Health, A
National Status Report, op.cit. p. 8.
6. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989. op.
cit.p. 11.
7. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects. 1986. ISBN 0-309-03730-1. p. 16.
8. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health Consequences
of Involuntary Smoking, a report of the Surgeon General. 1986. op cit. p. xxi.
9. ibid. p. 184.
10. CLAUSEN, G. Comfort and environmental tobacco smoke, unpub. article, 1989.
11. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989. op.
cit. p. 21.
12. WELLS, AJ. An estimate of adult mortality in the United States from passive smoking.
Environment International, vol. 14, 1988.
13. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 135.
PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 65
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14. WELLS, AJ, Passive smoking and adult mortality. Paper, 6th World Conference on
Smoking and Health, Tokyo, 1987. Public Smoking and Health 1987, Aoki M, Hisamichi S,
Tominaga S. (Excerpta Medica, Amsterdam, New York, Oxford, 1988)
15. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 14.
16. RICKERT, W., ROBINSON, JC, COLLINSHAW, N. Yields of tar, nicotine and carbon
monoxide in the sidestream smoke from 15 brands of Canadian cigarettes, American
Journal of Public Health 74(3): 228-231,1984
17. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, the Health Consequences
of Involuntary Smoking, A Report of the Surgeon General, op. cit. p.131.
18. RICKERT, W.S.; ROBINSON, J.C.;COLLISHAW, N.E. (1984) Sidestream Yields of Tar,
Nicotine, and Carbon Monoxide from 15 Brands of Canadian Cigarettes. Am. J. Publ. Health
74:228-231
19. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989. op.
cit. p. 82-85.
20. ibid, p. 486.
21. ibid, p. 85.
22. U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE. Smoking and
Health: A Report of the Surgeon General. 1979. DHEW Publication No. (PHS) 79-50066,11-5.
23. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 127-134.
24. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989. op.
cit. p. 50.
25. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 128.
26. SMITH, KR. Air pollution, assessing total exposure in the United States, Environment,
30(8): 37.1988.
27. SPENGLER, JD., DOCKERY, DW., TURNER, WA., WOLFSON, JM., FERRIS, BG, Jr.
Long-term measurements of respirable sulfates and particles inside and outside homes.
Atmospheric Environment 15(1):23-30, 1981.
66 PUBLIC REVIEW DRAFT ~ DO NOT CITE OR QUOTE
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28. SAMET, J., MARBURY, M., SPENGLER, J. Health effects and sources of indoor air
pollution, American Review of Respiratory Disease 136:1491/1987.
29. MIESNER, EA., et al. Report to the U.S. Environmental Protection Agency, Cooperative
Agreement No. CR 813526-01-0, Harvard School of Public Health, 1988.
30. REPACE, JL, LOWERY, AH. Indoor air pollution, tobacco smoke and public health,
Science 208:464-472,1980; Tobacco smoke, ventilation and indoor air quality, American
Society of Heating, Refrigerating and Air Conditioning Engineers, Inc. Transactions, 88
(part 1) 895-914,1982.
31. MEISNER, op. cit.
32. SAMET, J., MARBURY, M., SPENGLER, J. Health effects and sources of indoor air
pollution, op cit. p. 1491.
33. MCCARTHY, J., SPENGLER, J., CHANG, B. A personal monitoring study to assess
exposure to environmental tobacco smoke. Proceedings of the 4th International Conference
on Indoor Air Quality and Climate, Berlin (West), 17-31 August, 1987.
34. SPENGLER, JD., TOSTESON, TD. Statistical models for personal exposures data, Paper
presented at Environmetrics 81. Conference of the Society for Industrial and Applied
Mathematics, Alexandria, Virginia, April, 1981.
35. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects, op. cit. 137-145.
36. LUCK, W., NAU, H. Nicotine and cotinine concentrations in serum and urine of
infants exposed via passive smoking or milk from smoking mothers. Journal of Pediatrics,
107:816-20,1985.
37. U.S. ENVIRONMENTAL PROTECTION AGENCY, Health Effects of Passive Smoking:
Assessment of Lung Cancer in Adults and Respiratory Disorders in Children. 1990. p.
38. MCCARTHY, J., SPENGLER, J., CHANG, B. A personal monitoring study to assess
exposure to environmental tobacco smoke, op. cit.
39. WALLACE, LI et. al., Exposures to benzene and other volatile compounds from active
and passive smoking, Archives of Environmental Health 42(5):209-221, 1978.
40. ibid
41. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 230.
PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 67
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42. ibid. p. 230
43. CLAUSEN, GH, et al. Sensory irritation from exposure from environmental tobacco
smoke. Berlin IAQ Conference proceedings. 1987.
44. TRICHOPOULOS, D. et al. Lung cancer and passive smoking: conclusion of Greek study
(letter). Lancet 2:667-668,1983.
45. HIRAYAMA, T. Non-smoking wives of heavy smokers have a higher risk of lung
cancer: A study from Japan. British Medical Journal 282:183-185,1981.
46. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health Consequences
of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 10,13.
47. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects, op. cit.
48. AKIBA et.al., 1986; BROWNSON et al., 1987; CHAN and FUNG, 1982; CORREA et al.,
1983; GAO et al., 1987; GARFINKEL, 1981; GARFINKEL et al., 1985; G1LLIS et al., 1984;
HIRAYAMA, 1981a, 1984; HUMBLE et al., 1987; INOUE and MIRAIJAMA, 1988; KABAT
and WYNDER, 1984; KOO et al., 1987; LAM et al., 1987; LAM, 1985; LEE at al., 1986;
PERSHAGEN et al., 1987; SHIMIZU et al., 1988; SVENSSON et al., 1988; TRICHOPOULOS et
al., 1981; VARELA, 1987; WU et al., 1985.
49. U.S. ENVIRONMENTAL PROTECTION AGENCY, Health Effects of Passive Smoking:
Assessment of Lung Cancer in Adults and Respiratory Disorders in Children. 1990. p.
50. SPENGLER, JD. Exposures to air pollutants. Harvard School of Public Health. 1988
51. SPENGLER, JD. Exposures to air pollutants. Harvard School of Public Health. 1988
52. HOFFMAN, D., BRUNNEMAN, KD., HALEY, NJ. Absorption of smoke constituents by
nonsmokers. American Health Foundation, 1988.
53. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects. 1986. op. cit. p. 211.
54. ibid. p. 9.
55. ibid. p. 274
56. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects. 1986. op. cit. p. 9.
68 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE
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57. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 63-64.
58. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects. 1986. op. cit. p. 213-215.
59. GARLAND, C, BARRETT-CONNOR, E., SUAREZ, L., CRIQUI, MH., WINGARD, D.
Effects of passive smoking on ischemic heart disease mortality of nonsmokers. American
Journal of Epidemiology, 121(5):649,1985.
60. ibid. p. 649
61. NATIONAL RESEARCH COUNCIL, Environmental Tobacco Smoke, Measuring
Exposures and Assessing Health Effects, op. cit. p. 176-177.
62. GILLIS et al., 1984; LEE et al., 1986; SVENDSEN et al., 1987; HELSING et al., 1988;
HIRAYAMA, 1986; GARLAND et al., 1985; MARTIN et al., 1986; HE, 1989; HUMBLE et al.,
1990; HOLE etal., 1989.
63. HIRAYAMA, T. Cancer mortality in nonsmoking women with smoking husbands
based on a large scale cohort study in Japan, Preventive Medicine 13: 680-90,1980.
64. SANDLER, DP., EVERSON, RB., WILCOX, AJ. Passive Smoking in Adulthood and
Cancer Risk, American Journal of Epidemiology, 121:37-48, 1985.
65. SLATTERY, ML. et al. Cigarette smoking and exposure to passive smoke are risk factors
for cervical cancer. Journal of the American Medical Association, 261(11) March 17, 1989
66. SANDLER, DP., EVERSON, RB., WILCOX, AJ. Passive Smoking in Adulthood and
Cancer Risk, op cit. p. 37-48
67. SANDLER, DP. et al. Cancer risk in adulthood from early life exposure to parents'
smoking. American Journal of Public Health 75:487-92, 1985.
68. SANDLER, D.P., EVERSON, R.B., WILCOX, AJ. Cumulative Effects of Lifetime Passive
Smoking on Cancer Risk. Lancet 1:312-5, 1982
69. PRESTON-MARTIN, S. et al. N-nitroso compounds and childhood brain tumors: a
case-control study. Cancer Research 42:5240-5,1982
70. U.S. ENVIRONMENTAL PROTECTION AGENCY, Health Effects of Passive Smoking:
Assessment of Lung Cancer in Adults and Respiratory Disorders in Children. 1990. p.
PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE 69
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71. AKIBA et.al., 1986; BROWNSON et al., 1987; CHAN and FUNG, 1982; CORREA et al.,
1983; GAO et al., 1987; GARFINKEL, 1981; GARFINKEL et al., 1985; GILLIS et al., 1984;
HIRAYAMA, 1981a, 1984; HUMBLE et al., 1987; INOUE and MIRAIJAMA, 1988; KABAT
and WYNDER, 1984; KOO et al., 1987; LAM et al., 1987; LAM, 1985; LEE at al., 1986;
PERSHAGEN et al., 1987; SHIMIZU et al., 1988; SVENSSON et al., 1988; TRICHOPOULOS et
al., 1981; VARELA, 1987; WU et al., 1985.
72. REP ACE, J.L.; LOWERY, A.H. Risk Assessment Methodologies for Passive Smoking
Induced Lung Cancer, Risk Analysis, Vol. 10, No. 1, March 1990.
73. WILLIAMS, DC., WHITTAKER, JR., JENNINGS, WG. Measurement of nicotine in .
building air as an indicator of environmental tobacco smoke levels, Environmental Health
Perspectives, volune 60, p. 405-410,1985.
74. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 7.
75. U.S. ENVIRONMENTAL PROTECTION AGENCY, Residential Air- Cleaning Devices,
January 1990.
76. ELECTRIC POWER RESEARCH INSTITUTE. Manual on Indoor Air Quality. 1984.
Prepared by Lawerence Berkeley Laboratory, Berkeley California for the Energy Management
and Utilization Division, Electric Power Research Institute, Palo Alto, CA. EPRI EM-3469.
77. CLAUSEN, GH., MOLLER, SB., FANGLER, PO. The impact of air washing on
environmental tobacco smoke odor. In B. Seifert et al. (eds.) Proceedings of Indoor Air 87,
Berlin, 2:47-51, 1987
78. INTERNATIONAL AGENCY FOR RESEARCH ON CANCER. Tobacco Smoking. IARC
Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans, Vol. 38,
Lyon, IARC, 1986.
79. FINAL REPORT, TOBACCO USE IN AMERICA CONFERENCE, American Medical
Association, Federal Regulation of Tobacco Products, p. 13,1989
80. NATIONAL ACADEMY OF SCIENCES. The Airliner Cabin Environment: Air Quality
and Safety, p. 150,1986.
81. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Smoking and Health, A
National Status Report. 1990. op. cit. p. 9.
82. SEVENTH WORLD CONFERENCE ON TOBACCO AND HEALTH ABSTRACTS, A n
Analysis of the Scope and Content of Clean Indoor Air Legislation in the United States,
Rigotti N., Perth, 1990.
70 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE
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83. MAJOR LOCAL SMOKING ORDINANCES IN THE UNITED STATES, NIH
PUBLICATION NUMBER 90-479,1989.
84. SHIMP V. NEW JERSEY BELL, 145 N.J. Super 516. 368 A. 2nd 408.1976.
85. SMITH V. WESTERN ELECTRIC CO., 643 S.W. 2nd 10 Missouri Court of Appeals, 1982.
86. GORDON V. RAVEN SYSTEMS, INC. 462 A. 2nd 10 D.C. 1983.
87. LEE V. DEPARTMENT OF PUBLIC WELFARE, Suffolk County (MA) Superior Court,
C.A. #63777 (1985).
88. PLETTEN V. DEPARTMENT OF THE ARMY, Number 03810087 Equal Employment
Opportunity Commission, April 8,1983.
89. VICKERS V. VETERNS ADMINISTRATION, 549 F. Supp. 85, 86-87 W.D. Washington
1982.
90. PARODIV. MERIT SYSTEMS PROTECTION BOARD, 690 F., 2nd 731 9th Circuit 1982.
91. HAYES, J. State Ordered to Compensate Non-smoking Employee, Oregonian, 2/8/85.
92. MCCARTHY V. DEPARTMENT OF SOCIAL AND HEALTH SERVICES, 46 Wash. App.
125,730 P.2d 681,1986.
93. DIEFENTHAL V. CAB, U.S. Court of Apppeals, Fifth Circuit, August, 1982.
94. GRUSENDORF V. CITY OF OKLAHOMA CITY, 816 F 2d. 539 (10th Circ. 1987).
95. MINNESOTA DEPARTMENT OF HUMAN RIGHTS, D.C.A., Inc., Ref. No. E16971
(1988).
96. AMERICAN MANAGEMENT SOCIETY, Smoking Policies Survey, p. 7-9,1989.
97. SMOKING POLICY INSTITUTE, 90 Days to a Smoke Free Workplace, Simon and
Schuster, 1987.
98. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Smoking and Health, A
National Status Report. 1990. op. cit. p. 8.
99. KRISTEIN, MM. Economic issues in prevention, Preventive Medicine 6:252-64, 1977.
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100. KRISTEIN, MM. The economics of health promotion at the worksite, Health
Education Quarterly 9:27-36,1982.
101. KRISTEIN, MM. How much can business expect to profit from smoking cessation?
Preventive Medicine, 12:358-381,1983
102. KRISTEIN, MM. Economic issues related to smoking in the workplace, New York
State Journal of Medicine January, 1989.
103. WEIS, WL. No ifs, ands or butts-why workplace smoking should be banned.
Management World, p. 39-44, September, 1981.
104. WEIS, WL. Toward a smoke-free work environment, Employee Services Management,
April, 1985.
105. WEIS, WL. Increasing productivity through on-site smoking control, Health Care
Strategic Management, April, 1985.
106. WEIS, WL. A smoke cloud over tobacco's future, Business and Society Review,
Winter, 1985.
107. WEIS, WL. The smoke-free workplace: cost and health consequences, Paper presented
at the 5th World Conference on Smoking and Health, 1983.
108. AMERICAN MANAGEMENT SOCIETY, Smoking Policies Survey, op cit. p. 19.
109. MEMO FROM AETNA JANITORIAL SERVICE TO UNIGARD INSURANCE CO., July
6,1982.
110. LUCE, BR., SWEITZER, SO. Smoking and alcohol abuse: a comparison of their
economic consequences. New England Journal of Medicine, 1978.
111. NAUS, S.A. et al. Work injuries and smoking, Industrial Medical Surgery 35:880-881,
1966.
112. KRISTEIN, MM. How much can business expect to profit from smoking cessation? op.
cit.
113. U.S. DEPARTMENT OF HEALTH, EDUCATION AND WELFARE. Smoking and
Health: A Report of the Surgeon General. 1979. op. cit.
114. KRISTEIN, MM. How much can business expect to profit from smoking cessation?,
op. cit.
72 PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE
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115. WEIS, WL. The smoke-free workplace: cost and health consequences, Paper presented
at the 5th World Conference on Smoking and Health, 1983.
116. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 303.
117. ANNUAL MEETING OF THE AMERICAN PUBLIC HEALTH ASSOCIATION
ABSTRACTS, Excess Insured Health Care Costs from Tobacco Using Employees in a Large
Group Plan, Penner M., Chicago, 1989.
118. PERSONAL CORRESPONDENCE, Dr. C. Biscard, Pacific Bell Medical Director, April 1,
1990.
119. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General. 1986. p. 281
120. BEIL, LD., THOMPSON, M. Pacific Northwest Bell's approach to implementing a
no-smoking policy, Modem Job Safety and Health, October 14,1987.
121. ROCKEFELLER, K., Masters Thesis. University of Washington School of Public
Health. 1990.
122. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Public Health Service,
Centers for Disease Control, Morbidity and Mortality Weekly Report, Vol. 36, No. 22. 1987.
123. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Reducing the Health
Consequences of Smoking, 25 Years of Progress, a report of the Surgeon General, 1989. op.
cit. p. 582
124. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, The Health
Consequences of Involuntary Smoking, a report of the Surgeon General, op. cit. p. 284
PUBLIC REVIEW DRAFT - DO NOT CITE OR QUOTE . 73
ftUS. GOVERNMENT PRINTING OFFICE: 1990 748-159/20414
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TO: OTS LIBRARY STAFF . JUN 2 5 1990
FROM: TIM
NOTE THIS F.Y.I.:
EPA AND PASSIVE SMOKING
ACTION
On June 25,1990, EPA transmitted to its Science Advisory Board (SAB) for review
and comment two draft documents on Environmental Tobacco Smoke (ETS) entitled
Health Effects of Passive Smoking: Assessment of Lung Cancer in Adults and Respiratory
Disorders in Children (EPA/600I6-90I006A) and Environmental Tobacco Smoke: A Guide
to Workplace Smoking Policies (EPA/400/6-90/004.) Companion notices in the June 25,
1990 Federal Register also announce a simultaneous public review process, commencing
June 25,1990 and ending August 31,1990, in which the public is invited to comment on the
draft documents.
STATUS
Both documents are public review drafts. They have been released by the Environmental
Protection Agency only to solicit scientific and public input on their contents and, therefore,
do not represent Agency policy. Consequently, it is inappropriate to quote or cite
information from these documents until they are released in final form by the Agency.
DESCRIPTION OF DOCUMENTS
> ^ '
*> • '
The first document ~ Health Effects of Passive Smoking: Assessment of Lung Cancer
in Adults and Respiratory Disorders in Children —proposes to classify ETS according to
EPA's carcinogen risk assessment guidelines, to estimate the excess lung cancer deaths
attributable to ETS exposure, and to assess the association between passive smoking and
respiratory effects. The draft risk assessment was prej ared by the Human Health :
Assessment Group of the Office of Health and Environmental Assessment of the Office of
Research and Development at the request of the Indoor Air Division of the Office of
Atmospheric and Indoor Air Programs in the Office of Air and Radiation.
The second document — Environmental Tobacco Smoke: A Guide to ' Workplace
Smoking Policies — is intended to provide government and private sector decision-makers
with information on the technical basis for controlling involuntary exposure to
environmental tobacco smoke and to describe a variety of technical and policy options for
instituting effective smoking restrictions. The guide to workplace smoking policies is based
on the overall body of literature on passive smoking, including the 1986 reports of the
Surgeon General and the National Research Council. Its review has been timed to coincide
with the review of the risk assessment in order to ensure that up-to-date information from
the risk assessment would be incorporated into the guide to workplace smoking policies.
The draft workplace policy guide was prepared by the Indoor Air Division.
A third document under development — but not yet available for public review — is
a Technical Compendium of Information on Environmental Tobacco Smoke. This
document was jointly conceived and funded by several agencies of the Department of
Health and Human Services in addition to EPA, including the Office on Smoking and
Health (Centers for Disease Control), the Office of Disease Prevention and Health
Promotion (Public Health Service) the Heart, Lung and Blood Institute, and the National
Cancer Institute (National Institutes of Health). The compendium consists of individual
-------
-------
U.S. ENVIRONMENTAL PROTSCS20N AGENCY
Environmental Tobacco Smoke: A Guide tq; Workplace Smoking
Policies " ' vrn :.iu/;\
AGENCY: U.S. Environmental Protection Agency
ACTION: Notice &f, availability ef external review draft andT
c, - .• •:>-' . ,.:*ari *.Q •>• •,-,, " .UUy-i j.i'i
request for public eemmentSo ^ -;j «v:v, V: j --'•• -•'-'• ,,„•,, .y
SUMMARY: This notice announces the"•availability of"thV'e"xternal
review draft of Environmental Tobaceo SEQke: A Guide to
.' JJ-H ^.oaap/. •• (-• •,; -> •.••^.;.;
Workplace Smoking Policies, «-.
( ' "'"--• •'- ''6 976 s?iqco i .• - -r'-x^m ' ' - .; /.-
EPA/400/6-SO/004.
,. .. . ,
This doGpje©nt will b@ the sufejsct of- a -Science Advisory
.. v «. r '\ i
Board (SAB) Meeting. The SAB is being asked t© review the manner
in which EPA cfearaeterizes in this docuffleat the scientific
informatics availals.l* &n environmental tobacco smoke. Notice of
the date and place of the SAB meeting
subsequent Federal Register notice. ;..,..! i v'-Jf'", '" .f4;\,0> t"";'TFlfIT • -- 4
^ ' -J/->^ ->uduq .cjij /.Jr/v bao.-vo-'fT st.ia
DATES: The Ag©nsy will make the draft document available for
public review and comment on or about Monday; rJuW 1*25 7 1990'.' Mci
• ' 'TvC) l-Sl^O -•:,:?•• • JO
Comments must be postmarked by Friday, AugustT^i'p 19.90 .C. D;>, v- «.-•.,
ADDRESSES: To obtain a single copy of the draft document,
interested parties should contact the ORD Publications Office,
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CERI-FRN, U.S. Environmental Protection Agency, 26 West Martin
Luther King Drive, Cincinnati, OH 45268, (513)569-7562 or
FTS/684-7562. Please provide your name and mailing address and
request the external review draft by title and EPA number.
The draft document also will be available for public
inspection and copying in the Public Information Reference Unit
of the EPA Library, U.S. Environmental Protection Agency
Headquarters, Waterside Mall, 401 M Street, SW, Washington, DC
20460.
Commenters are requested to submit their comments in writing
to: Project Officer for ETS Policy Guide, Indoor Air Division
(ANR-445) , Environmental Protection Agency, 401 M Street, SW,
Washington, DC 20460. FAX* (202)382-7991.
FOR FURTHER INFORMATION CONTACT: Bob Axelrad, (202)475-8470 or
FTS/475-8470.
SUPPLEMENTARY INFORMATION: The Quid* to Workplace Smoking
Policies is intended to provide government and private sector
decisionmakers with information on the technical basis for
controlling involuntary nonsmoJcer exposure to environmental
tobacco smoke and to describe the range of technical and policy
options for instituting effective smoking policies.
JUN 1 9 1990
Michael Shap
(Date) Deputy Assistant Administrator for
Air and Radiation
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