OMA position paper on second hand smoke
OMA position paper on second-hand smokeby OMA Committee on Population
HealthNovember 1996 Introduction The physicians of Ontario have
long been involved with health promotion and preventive medicine, as reflected
in their battles for the pasteurization of milk, the chlorination of water, asbestos
removal, the vaccination of all Ontario school children, and seat-belt legislation
(which caused controversy over "forcing" people to buckle up). The OMA has always
taken a strong stand against society's number one preventable public health problem,
tobacco use. As far back as 1974, the OMA identified the need to protect those
who do not use tobacco products, yet are exposed to the byproducts of smoking.
A 1983 OMA conference on passive smoking highlighted the Association's concern
with regard to second-hand smoke,* and brought this important health issue to
the attention of major organizations and groups of influence in the community.
Physicians were urged to discourage smoking in their workplaces, including hospitals,
offices and waiting rooms, to protect patients and staff from the dangers of second-hand
smoke. Second-hand smoke ranks third as a major preventable cause of death
behind only active smoking and alcohol.1 Second-hand smoke is the smoke
that individuals breathe when they are located in the same air space as smokers.
Second-hand smoke is a mixture of exhaled mainstream smoke from the tobacco user,
sidestream smoke emitted from the smoldering tobacco between puffs, contaminants
emitted into the air during the puff, and contaminants that diffuse through the
cigarette paper and mouth end between puffs.2 Second-hand smoke is
a complex mix of over 4,000 substances, of which more than 42 individual mainstream
components are known to cause cancer in humans and animals, and many of which
are strong irritants.3 Sidestream smoke contains many of the same substances
found in mainstream smoke, including a host of carcinogenic agents.4
Smokers themselves are compromised not only from the smoke directly inhaled
from tobacco use, but by second-hand smoke as they breathe in both the sidestream
and mainstream smoke. There is a need to aggressively combat this health hazard.
There are segments of the population which, despite the evolution of attitudes
toward open recognition of this problem, continue to put others at risk and view
the problem merely as a nuisance. However, second-hand smoke is one of the major
environmental health risks that society faces today, and steps can and must be
taken to prevent this health hazard. The purpose of this document is to outline
the position of the OMA with respect to second-hand smoke. Its deleterious effects
are particularly significant when one takes into account the fact that second-hand
smoke usually victimizes non-smokers against their will. The recommendations included
in this report will, if acted upon, lead to a significant reduction in the overall
involuntary exposure of non-smokers, especially children, to second-hand smoke.
The health hazards of second-hand smokeFor
more than 30 years, the U.S. Surgeon General's reports, based on strong scientific
evidence, have identified tobacco use and exposure to second-hand smoke as serious
public health hazards. In 1986, reports by both the U.S. National Research Council
and the U.S. Surgeon General concluded that second-hand smoke causes lung cancer
in adult non-smokers, and that children of parents who smoke have an increased
frequency of respiratory symptoms and acute lower respiratory tract infections,
as well as evidence of reduced lung function.5, 6 These facts were confirmed and
strengthened by the 1992 U.S. Environmental Protection Agency (EPA) assessment
of the health effects of second-hand smoke.7 A scientific consensus
has emerged during the past 10 years that second-hand smoke is a major cause of
lung cancer and respiratory disease in young people. More recently, evidence has
accumulated of a causal link to heart disease. These facts have led to a growth
in concern for the health of individuals not addicted to tobacco, but exposed
to second-hand smoke. I. Lung cancerSecond-hand
smoke is the third-ranking known cause of lung cancer after active smoking and
indoor radon. Exposure to second-hand smoke during adult life increases the risk
of lung cancer in non-smokers. Lung cancer now kills more women than breast cancer,
and is the second leading cause of premature death for men. The 1992 EPA report
confirms that second-hand smoke is a human lung carcinogen, and is linked to 3,000
lung cancer deaths annually in the U.S.8 Since in this case geographic
and cultural differences are probably not significant, it can be assumed that
the numbers are proportionately similar in Canada and Ontario. The cancer mortality
from second-hand smoke alone is greater than the combined mortality from all regulated
environmental carcinogens.9 II. Heart diseaseHeart
disease has multiple risk factors. For this reason, the scientific community has
taken longer to conclude that tobacco use causes heart disease. The Surgeon General's
1986 report suggested a linkage between exposure to second-hand smoke and heart
disease. Results of recent epidemiological studies, in combination with a variety
of available physiological and biochemical data, have led many researchers to
conclude that second-hand smoke causes heart disease. It is now well established
that tobacco use is the most important preventable cause of heart disease. As
a result of exposure to second-hand smoke, there is an acute compromise of the
coronary circulation, which is effected as reduced exercise tolerance in healthy
individuals and in those with existing coronary artery disease, platelet activation,
and abnormalities of vasodilation. Injury to the arterial lining, the first step
in the development of atherosclerosis, is caused by the carcinogenic agents in
second-hand smoke, such as benzo(a)pyrene and 1, 3 - butadiene.10,
11 Heart disease morbidity and mortality is far more serious than
lung cancer as a contributor to the bulk of the public health burden caused by
second-hand smoke. It is estimated that 69 per cent of the second-hand smoke-related
deaths in the U.S. are due to heart disease, compared with 31 per cent due to
lung cancer.12 In 1993, the first Ontario Heart Health Survey noted
that cardiovascular disease, the leading cause of death in Ontario, is responsible
for 35 per cent of all deaths in Ontario.13 The elimination of involuntary
exposure to second-hand smoke would therefore have a significant impact on mortality
related to heart disease. III. Children and second-hand
smokeThe 1994 U.S. Surgeon General's report states that second-hand
smoke harms children. Children who breathe second-hand smoke have more ear infections,
more severe asthma attacks and more breathing problems than children who live
in smoke-free homes.14 Where tobacco use is allowed, children often
have no way of protecting themselves from exposure to second-hand smoke. The
1994 Surgeon General `s report also discusses the increased neonatal and infant
mortality rates for children whose parents smoke. The pathological arterial change
which causes atherosclerosis has also been observed in the umbilical arteries
of infants born not only to mothers who smoke, but also to mothers who have been
exposed to second-hand smoke.15 Paternal as well as maternal smoking
is associated with low infant birth weight. Parental smoking is also a significant
risk factor for postnatal deaths, especially due to respiratory disease and sudden
infant death syndrome (SIDS).16 There is sound evidence that exposure
to second-hand smoke in childhood is associated with an increased probability
of developing asthma among certain at-risk children, and suggestive evidence that
children who are not at risk and are exposed to second-hand smoke may have a higher-than-average
risk of developing asthma. For asthmatic children, second-hand smoke has a causal
role in asthmatic-related morbidity. Exposure to second-hand smoke represents
a serious pediatric problem which has been estimated to double the risk of infection
and death in children.17 They must be protected from the adverse health
hazards of involuntary exposure to second-hand smoke.
IV. Second-hand smoke in the workplace and public placesExposure of children
and adult non-smokers to second-hand smoke in public places and workplaces remains
widespread. Since 1980, second-hand smoke has been identified as a leading occupational
health hazard. If no workplace smoking restrictions exist, non-smokers are most
exposed to second-hand smoke in the workplace. Second-hand smoke should be regulated
out of both workplaces and enclosed public places in order to protect non-smokers
from involuntary exposure.18 ** Many studies have now confirmed
that workplace and public place smoking restrictions facilitate some smokers to
stop using tobacco products and others to use them less. Contrary to tobacco industry
propaganda, smokers comply with workplace smoking restrictions; most labor groups
agree that non-smokers should not be exposed to second-hand smoke.19
Restaurants and bars, which are both worksites and enclosed public places,
have not been regulated in any significant manner in Ontario in order to protect
non-smoking employees and non-smoking customers from second-hand smoke exposure.
Recent studies indicate that levels of exposure to second-hand smoke are higher
in restaurants and bars than in office workplaces or other businesses. Workers
in restaurants and bars must be given the same public health protection as federal
and provincial employees, especially due to the formers' increased risk of lung
cancer and heart disease because of the higher level of exposure to second-hand
smoke.20, 21 Restaurant and bar owners are concerned
that smoking restrictions within their establishments will result in a decrease
in revenue. A study by Glantz and Smith found no significant effect on restaurant
sales as a result of a total ban on smoking in restaurants in certain California
cities.22 At least 211 U.S. cities have now adopted smoke-free restaurant
bylaws23 and, based on a recent survey, four per cent of Toronto restaurants
are smoke-free, following the implementation of the January 1993 Toronto smoking
control bylaws.24 As of January 1996, Toronto City Council implemented
a ban on tobacco use in food courts. Also in January 1996, the City of Vaughan
in the Greater Toronto Area voted to end smoking in all workplaces and public
places, including restaurants, effective May 1996. A significant step forward
for tobacco control was taken on July 2, 1996, when Toronto City Council amended
the municipal code, chapter 301, smoking, to prohibit smoking in restaurants and
entertain- ment facilities, effective January 1, 1997. The bylaw was amended on
October 8, 1996, to allow a provision for designated smoking rooms (separately
enclosed, separately ventilated rooms which do not exceed 25 per cent of the restaurant
or bar seating area). The implementation date was amended to March 3, 1997, to
allow proprietors more time to implement the bylaw amendments. Canadian airlines
and many U.S. airlines fly smoke-free worldwide, thereby protecting both their
non-smoking employees and non-smoking clients. Customers who use tobacco are able
to forego its use during flights, and therefore should also be able to forego
tobacco use when dining out. Recommendations I. Given
the serious health impact of second-hand smoke and the increasing social consensus
on the dangers of both smoking and the exposure to second-hand smoke, all Ontario
workplaces and enclosed public places must be smoke-free. A 1994 research survey
by Ashley et al.,25 indicates that a clear majority of both smoking
and non-smoking Ontarians agree that local government should enact and enforce
tobacco control restrictions. A 1994 Addiction Research Foundation survey indicated
that Ontarians are now far more supportive of most tobacco control measures than
they were only two or three years ago. One factor resulting in this change is
a greater concern with increases in smoking due to the availability of cheaper
tobacco products.26 Current scientific evidence indicates that there
is no safe level of exposure to any carcinogenic substance. Second-hand smoke,
the number one cause of environmental cancer, must be eliminated from the workplace
and enclosed public places. Eliminating second-hand smoke from the workplace and
enclosed public places can no longer be considered a debatable issue, but must
become a reality.27 Given the number of estimated deaths from both
heart disease and lung cancer due to exposure to second-hand smoke, it should
be viewed as an environmental toxin from which the public and workers should be
protected. It behooves employers and public building managers to protect the workers
and the public respectively from involuntary exposure to second-hand smoke.28
Another important factor for employers to consider is the risk of liability lawsuits
from workers who have been exposed to second-hand smoke in the workplace. There
have been successful cases in several jurisdictions. Legislators must now strive
to meet the goals set out in the Ontario Tobacco Strategy, which include protecting
the public from second-hand smoke. Also articulated as a goal is making all schools,
workplaces and public buildings smoke-free by 1995.29 The Tobacco Control
Act (TCA) 1994, was the Ontario government's first step toward meeting this goal.
It is imperative that the government now amend the Smoking in the Workplace Act
to eliminate second-hand smoke exposure in the workplace, and expand the ban under
the TCA to include all enclosed public places, especially those frequented by
children. Completely smoke-free workplaces and enclosed public places is the least-costly
policy to implement.30 II. Given the known
and serious health impacts of second-hand smoke on not only children and adolescents,
but also to the child in utero, steps must be taken so that smoking in all places
frequented by pregnant women, young children, and adolescents is eliminated. Elimination
of exposure to second-hand smoke in infancy is especially important as early lung
development appears to be a critical determinant of respiratory health.31
Children of parents who use tobacco may be exposed to second-hand smoke levels
in the home which may approach the levels found in bars, creating exacerbated
respiratory hazards for them. The only suitable control measure is tobacco use
outside the home.32 Parents must not ignore their responsibility
to protect their children from involuntary exposure to second-hand smoke, especially
exposure which will increase the children's risk of second-hand smoke-related
death in the future.33 Based on current information on ventilation
systems, second-hand smoke can persist indoors for many hours after tobacco use.34
Parental tobacco use in another room in the house is therefore similar to having
urination allowed only in the deep end of a pool. Several newspaper reports
have noted parental and societal changes in attitude toward the exposure of young
children and adolescents to second-hand smoke. In a 1992 Chicago custody case,
a father would have lost the right to have access to his son had he not agreed
to stop smoking in his son's presence.35 More recently in Vancouver,
a father of three wanted his estranged wife to stop smoking in the presence of
their young children, as he was concerned about the effects of second-hand smoke
on their health. The wife's lawyer advised her that although the issue would be
dealt with in court, she should deal with the problem appropriately and "perhaps
not smoke in the presence of the children."36 New guidelines for
adoption and fostering agencies have been developed in Britain which prohibit
smokers from adopting or caring for young children.37 The rationale
is based on the known health dangers of second-hand smoke exposure, especially
for children under two years of age, as well as the known risk for SIDS, which
is increased two-fold when the caring adult smokes. Children exposed to smoking
in the home are not only susceptible to the health hazards of second-hand smoke,
but are also more likely to start using tobacco products themselves. Therefore,
decreased second-hand smoke exposure should result in reduced illness in children
and fewer young people who start to use tobacco products. Opponents to total
elimination of second-hand smoke often raise issues related to individual rights
and freedom. However, smokers can choose not to smoke, but non-smokers cannot
choose not to breathe. Exposure to second-hand smoke is a health issue and should
be dealt with in the same manner as other environmental toxins. Those who argue
that smoking is a "right" or an "adult choice" ignore two critical facts: ·
An addicted smoker is not exercising his/her "rights" by smoking, but rather is
satisfying a craving for a highly addictive drug, nicotine; · In smoking,
a smoker is forcing involuntary second-hand smoke exposure on non-smokers, with
health impacts on individuals, including children, not just on the tobacco user.38
The concept of state intervention in the home and other private places often
raises significant controversy and must be addressed with care, caution and considerable
thought. Notwithstanding this, the concept is not a new one. The homes that we
live in and the cars that we drive are strictly regulated. There are building
and electrical codes, regulations banning the use of certain products, such as
cribs painted with lead-based paint, regulations which determine who can and cannot
drive an automobile, and there are laws against domestic violence and child abuse.
The home is considered a place of private respite. Yet, as stated above, certain
activities such as child abuse, even if carried out in the privacy of one's own
home, are subject to legal sanctions. Likewise, although the parent-child relationship
has special status, this status does not extend to allowing a parent to cause
harm to a child. Parental tobacco use in the home, resulting in the inhalation
of known carcinogens and asthmagens by children, is a form of physical abuse.39
The development and passage of laws and regulations leading to a very significant,
if not total, reduction of smoking in all public places frequented by pregnant
women, young children and adolescents, will be accompanied by debate and opposition.
But as with other laws which have resulted in a significant positive health impact
on the public and are based on solid evidence, once a social consensus exists
that elimination of children's exposure to second-hand smoke is necessary and
appropriate, both smoke-free homes and public places will, like the use of seat-belts
in cars, become the accepted norm. III. Given the challenge
we face in determining the best method of eliminating second-hand smoke in the
home in a manner which is socially acceptable, an expert work group should be
convened including, but not limited to, individuals with expertise in law, medicine,
civil and individual rights, and ethics, to consider the issue comprehensively.
Three decades of scientific study have demonstrated that the benefits of the
elimination of second-hand smoke exposure far outweigh the risks inherent in such
dramatic action. Second-hand smoke elimination must be viewed as a positive and
necessary step in maintaining and enhancing the health of the entire population.
The exposure of children and adult non-smokers to second-hand smoke, a known human
carcinogen, can and must be viewed as being a direct violation of the rights of
all non-smokers, but particularly those of children, who, in contrast to most
adults, frequently have no choice but to be exposed to second-hand smoke on a
daily basis. Conclusion The
purpose of this document is to outline the position of the OMA concerning the
growing public health problem of second-hand smoke. Second-hand smoke is one of
the major environmental health risks facing society today and steps can be taken
to significantly eliminate this health threat. When asbestos and PCBs were identified
as environmental health risks, action was taken and these items were appropriately
banned from use. It must be noted that the number of deaths and illnesses related
to the exposure to both as- bestos and PCBs has been significantly less than the
number of deaths from second-hand smoke alone. The best cure for second-hand
smoke-caused illnesses in our communities is known without further research elimination
of involuntary exposure to second-hand smoke. A smoke-free environment in public
buildings, workplaces, and in the home, should be the goal of society.40 This
issue is a serious one requiring an integrated and comprehensive approach involving
many stakeholders, including the active involvement of organized medicine. While
cognizant of barriers to the implementation of these recommendations, the OMA
believes that the end benefits far outweigh the obstacles. The result would be
a healthier society, and in particular, healthier children. The challenge we face
is to determine the best method to entirely eliminate second-hand smoke in a manner
which is socially acceptable. The OMA urges every community, including health-care
providers, educators (especially of youth), parents and legislators to address
the issue of second-hand smoke in an aggressive and timely fashion.
Endnotes 1. Glantz SA, Parmley WW. Passive smoking
and heart disease: Epidemiology, physiology, and biochemistry. Circulation , 1991:83;1-12.
2.Environmental Protection Agency. Respiratory health effects
of passive smoking: Lung cancer and other disorders. Washington, D.C.: Office
of Health and Environmental Assessment, 1992. 3.
Ibid. 4. Ibid.
5. National Research Council. Environmental tobacco smoke: Measuring
Exposure and Assessing Health Effects. Washington, D.C., National Academy Press,
1986. 6. U.S. Department of Health,
Education and Welfare: Smoking and Health. Report of the Advisory Committee to
the Surgeon General of the Public Health Service. Washington, D.C., PHS Publication
No. 1103, 1964. 7. Environmental
Protection Agency, 1992. Ibid. 8.
Villeneuve PJ. Lifetime probability of developing lung cancer by smoking status,
Canada. Canadian Journal of Public Health , 1994:85(6): 385-388.
9. Repace JL, Lowrey AH. Risk assessment methodologies for passive-smoking-induced
lung cancer. Risk Analysis , 1990:10:27-37. 10.
Glantz, 1991. Ibid. 11. Penn A, Snyder
CA. 1,3 Butadiene, a vapor phase component of environmental tobacco smoke, accelerates
arterioslerotic plaque development, February 1, 1996: 93(3);552-7.
12. Glantz, 1991. Ibid. 13.
Ministry of Health. Ontario Heart Health Survey, Toronto: Queen's Printer, 1993.
14. U.S. Department of Health and Human Services. Preventing
tobacco use among young people: A report of the Surgeon General. U.S. Department
of Health and Human Services, Public Health Service, Centres for Disease Control
and Prevention, International Centre for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1994. 15.
U.S. Department of Health and Human Services, 1994. Ibid.
16. Klonoff-Cohen HS. The effect of passive smoke and tobacco
exposure through breast milk on sudden infant death syndrome. Journal of the American
Medical Association , March 8, 1995:273;795-798. 17.
Gridding SS, et al. Active and Passive Tobacco Exposure: A serious pediatric health
problem: A statement from the committee on atherosclerosis and hypertension in
children, council on cardiovascular disease in the young, American Heart Association.
Circulation , November, 1994:90(5);2581-2590. 18.
Siegel M. Smoking and restaurants: A guide for policy-makers, UC Berkeley/USCF
Preventive Medicine Residency Program, American Heart Association, California
Affiliate, Alameda County Health Care Services Agency, Tobacco Control Program,
September 1992. 19. Environmental
Protection Agency, 1992. Ibid. 20.
Siegel M. Involuntary smoking in the restaurant workplace. Journal of the American
Medical Association , 1993:270;490-493. 21.
Siegel M, 1992. Ibid. 22. Glantz
SA, Smith LR. The effect of ordinances requiring smoke-free restaurants on restaurant
sales. American Journal of Public Health , 1984:84;1081-1085.
23. Ying JYC, Abernathy T, Choi BCK. A Comprehensive Evaluation
of the 1993 City of Toronto Smoking Bylaws. Canadian Journal of Public Health
, 1995:86(1). 24. Repace JL, Lowrey
AH. Issues and answers concerning passive smoking in the workplace: rebutting
tobacco industry arguments. Tobacco Control , 1992:1;208-219.
25. Ashley MJ, SB, Pederson LL. Restrictive measures on smoking
in Ontario: Similarities and differences between smokers and non-smokers in knowledge,
attitudes, and predictive behavior and implications for tobacco programs and policies.
Ontario Tobacco Research Unit, Working Papers Series, Number 1, Toronto, 1994.
26. Pagilia A. Report of the 1994 Ontario Alcohol and Other Drugs
Opinion Survey, Addiction Research Foundation Survey #121, 1995.
27. EPA, 1992. Ibid. 28.
Taylor AE, Chairman, Johnson, DC, Kazenic H, members. Environmental tobacco smoke
and cardiovascular disease, a Position Paper from the Council on Cardiopulmonary
and Critical Care, American Heart Association. Circulation , 1992:86;699-702.
29. Ontario Tobacco Research Unit, Monitoring Ontario's tobacco
strategy, progress towards our goal, October, 1995.
30. Repace JL, Lowrey AH. An enforceable indoor air quality standard
for environmental tobacco smoke within the workplace. Risk Analysis , 1993:13;463-475.
31. Gridding SS, et al, 1994. Ibid.
32. Repace JL. Risk management of passive smoking at work and
home, St. Louis XIII, 1994:763-785. 33.
Taylor AE, 1992. Ibid. 34. Ibid.
35. "Father will butt out to keep seeing son." Halifax: Halifax
Daily News , January 16, 1992. 36.
"Dad fumes over wife's smoking." Toronto: Sunday Sun , March 5, 1995.
37.Smokers rejected as adoptive parents. The Journal, Addiction
Research Foundation 1993, May 22(3):7. 38.Ezra
DB. Sticks and stones can break my bones, but tobacco smoke can kill me: Can we
protect children from parents that smoke? Saint Louis University Public Law Review
, 1994:13(2);547-590. 39. Ezra DB,
1994. Ibid. 40. Taylor AE, 1992.
Ibid. Footnotes *Second-hand
smoke is also referred to as environmental tobacco smoke, involuntary smoking
or passive smoking. The term second-hand smoke is used throughout this document.
** The workplace, in this document, is defined as any enclosed area of a building
or structure in which an employee works and includes washrooms, corridors and
common areas utilized by an employee.
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