The Truth About Secondhand Smoke Excerpted from Consumer Reports electronic services January 1995, reprinted by permission. Introduction In the 1950s and 1960s, the tobacco industry mounted a campaign to keep doubt alive about the consequences of smoking. The effort ultimately flopped. But it succeeded in putting off that day when everyone acknowledged the hazard. That delay bought years of robust sales. The industry is at it again, only this time the target is secondhand smoke. The Evidence? For years, researchers have accumulated information about the effects of the compounds in secondhand smoke. Cigarette smoke and tars condensed from it induce cancer in laboratory animals. The smoke causes genetic mutations in bacteria, another common test for carcinogenic potential. And several of its components are known or probable human carcinogens. If scientists had only this animal and laboratory evidence to go on, secondhand smoke would still qualify as a "probable" or "possible" human carcinogen. Tobacco smoke is among a handful of substances (including asbestos, vinyl chloride and radon) for which abundant human evidence exists. That evidence comes from epidemiology (the study of disease patterns in human populations), the field responsible for identifying all the known human carcinogens. There are 33 published epidemiological studies of secondhand smoke, 13 of which were conducted in the U.S. Most used standard epidemiological technique. The published studies looked at nonsmoking women who developed lung cancer, to see whether they were more likely to be married to smokers than were women who didn't get the disease. In all such studies, it is difficult to accurately measure every variable. Most of the smoking occurred decades ago, and the details can't be learned. Some women whose husbands didn't smoke might still have breathed smoke at work or with friends. And some wives of smokers might have been able to avoid their spouses' smoke. But both of those factors would tend to hide any true relationship between exposure and disease. So, if anything, the studies should underestimate the risk of secondhand smoke. Despite the unknown variables, 26 of the 33 studies indicated a link between secondhand smoke and lung cancer. Those studies estimated that people breathing secondhand smoke were 8 % to 150 % more likely to get lung cancer sometime later. Of the remaining seven studies, one found no connection with lung-cancer rates. Six suggested that people exposed to secondhand smoke had lower rates of lung cancer, although no one suggests passive smoking really reduces the risk. Seven of the 26 positive studies included enough subjects, and found a sufficient effect, to attain "statistical significance," meaning there was no more than a 5 % probability that the results in those studies occurred by chance. In contrast, just one of the negative studies reached statistical significance. Strength in Numbers The nonsignificant studies can still be valuable when combined with all the rest for analysis. This technique, called meta-analysis, is commonly used with carefully designed clinical trials of drugs. The use of meta-analysis in epidemiology is controversial, since no two studies have identical designs and the analysts must make certain assumptions as they combine data. So, the result of a meta-analysis is supporting evidence but is not definitive by itself. Six different meta-analyses have been carried out on the secondhand-smoke studies. Every one of them yielded a statistically significant increase in lung-cancer risk of approximately 20 % to 40 %. Early in 1993, the U.S. Environmental Protection Agency (EPA), after a painstaking and wide-ranging scientific review, declared secondhand smoke a known, not just "probable," or "possible," human carcinogen. The EPA found an increased risk of 19 % among U.S. nonsmokers married to smokers. It estimated that such smoke is responsible for several thousand cases of lung cancer in U.S. nonsmokers each year. Passive smoke thus joins a select company of only about a dozen other environmental pollutants in this risk category. More evidence for a link between cancer and secondhand smoke comes from 19 of the 33 published epidemiological studies, which grouped subjects into exposure categories. In every one of those studies, women exposed to the most smoke for the most years had higher cancer risks than women exposed to less smoke. That dose-response relationship (an increase in risk with an increase in exposure) is an important indication of a true cause-effect relationship. Evidence for a dose-response relationship got important support from the most recent secondhand-smoke study, published last summer by epidemiologist Elizabeth Fontham of Louisiana State University Medical Center. The largest such study ever done, it's also considered by experts in the field to be the best in design and execution. Fontham found increased risks of lung cancer with increasing exposure to secondhand smoke. A spouse's smoking alone produced an overall 30 % increase in lung-cancer risk. Women with the greatest lifetime exposure (smoking parents, husbands, friends, coworkers) had a 225 % increase in risk. For any given nonsmoker, the lifetime risk of getting lung cancer remains small: 4 to 5 in 1,000 ordinarily, 6 to 7 in 1,000 if he or she has a smoking spouse. But exposure to secondhand smoke is so commonplace that, according to the EPA's calculations, it produces an extra 3,000 lung-cancer deaths among adults in the U.S. each year. That makes secondhand smoke the third-ranking known cause of lung cancer, after active smoking and indoor radon. Respiratory Problems Despite all the attention given to lung cancer, it may not be the most significant health effect of secondhand smoke. Two others stand out as well: respiratory problems in children and heart disease in adults. The ill effects of smoke on children begin even before birth, since many of the components of smoke reach the developing fetus through the mother. Infants born to smoking mothers weigh less and have weaker lungs than unexposed newborns. Regardless of birth weight, babies born to smoking mothers are more likely to die in infancy than unexposed infants. Whether from prenatal effects or from secondhand exposure to smoke after birth, children reared around smoking parents have about twice as many respiratory infections (bronchitis and croup, for example) as the children of nonsmokers. After reviewing a number of studies, the EPA's risk analysis concluded that secondhand smoke causes an extra 150,000 to 300,000 respiratory infections a year among the nation's 5.5 million children under the age of 18 months. Asthma also turns out to be about twice as common in children exposed to high levels of secondhand smoke. Wheezing from asthma and cough from bronchial irritation occur more frequently among children of smokers. And among children with asthma, living with smoking parents markedly worsens the disease. The EPA blames secondhand smoke for causing between 8,000 and 26,000 new cases of childhood asthma a year, and for aggravating the condition in about 200,000 children. "Children just should not be around people smoking," says Ross Brownson, professor of epidemiology at the St. Louis University School of Public Health. Heart Disease The epidemiological evidence on secondhand smoke and heart disease is not as abundant as that on lung cancer, and the experts are still debating the implications. But about a dozen studies exist, and they consistently show an elevated risk. Among nonsmokers who are exposed to their spouses' smoke, the chance of death from heart disease increases by about 30 %. (The effects of active smoking on the heart were established some years ago. Smoking about doubles a person's chance of dying from a cardiovascular condition.) A number of authorities have already declared secondhand smoke a risk factor for heart disease. They include the states of California and Maryland, the U.S. Occupational Safety and Health Administration (OSHA), the American Heart Association, and the American College of Cardiology. They point not only to the epidemiological evidence, but to animal studies, which have shown that exposure to specific elements of secondhand smoke causes blood to clot more easily and damages arterial linings, two critical steps in the development of heart disease. Human studies show that the carbon monoxide in secondhand smoke decreases the supply of oxygen reaching the heart muscle, which could cause serious problems for someone with coronary heart disease. If exposure to secondhand smoke does increase the risk of heart disease by 30 %, then it's causing an estimated 35,000 to 40,000 deaths a year in the U.S., about 10 times the number of lung-cancer deaths attributed to secondhand smoke. That would make the annual toll from secondhand smoke comparable to that from motor-vehicle accidents. The Tobacco Industry's Campaign The tobacco industry foresaw the health debate over secondhand smoke, and the problems it would cause for cigarette makers. In 1978, a Roper poll commissioned by the Tobacco Institute, the industry's trade group, called growing public concern about secondhand smoke "the most dangerous development yet to the viability of the tobacco industry" and recommended "developing and widely publicizing clear-cut, credible medical evidence that passive smoking is not harmful." In 1986, Imperial Tobacco Ltd., Canada's largest cigarette company, commissioned a secret study on how to combat the growing success of anti-smoking activists. The study documents, made public in the course of a lawsuit, lay out in prescient detail the industry's current strategy on secondhand smoke: "Passive smoking [should be] used as the focal point.... Of all the health issues surrounding smoking...the one which the tobacco industry has the most chance of winning [is] that the evidence proclaimed by the anti-group is flawed.... It is highly desirable to control the focus of the debate." The study's documents go on to urge "an attack on the credibility of evidence presented to date." The ideal advocate would be a medical professional, the report said, but "the challenge will be to find a sympathetic doctor who can be demonstrated to take a largely independent stance." The recommended message on secondhand smoke: "Now that you have seen that all which has been said is not true, let's be adult and get down to the real business, a respect for each other's choices and space." Whether or not tobacco companies ever saw the report, their current public-relations campaign is following its advice. Influencing Science In its efforts to construct the sort of "credible medical evidence" its pollsters recommended, the tobacco industry has commissioned research from sympathetic scientists, sponsored scientific meetings carefully tailored to bring out their point of view, and published the results in the medical literature. The research support comes through various channels: direct grants from companies or industry-funded research institutes -- such as the Council for Tobacco Research and the Center for Indoor Air Research) -- and consulting contracts from tobacco companies, public-relations firms, and law firms. To get favorable research on the record, the tobacco industry has borrowed a technique from the pharmaceutical industry: sponsoring scientific symposia and seeing to it that their findings end up on medical library shelves. Lisa Bero, a health policy analyst at the University of California, San Francisco, has documented the results of such symposia. She identified four symposia between 1974 and 1990 that were paid for by the tobacco industry. Only 4 % of the articles from the industry-funded symposia said that passive smoking was unhealthful, compared with 65 % of the other journal articles. Fully 72 % of symposia reports argued that secondhand smoke wasn't harmful, compared with 20 % of independent journal articles. (The balance was neutral.) The symposium reports did not undergo the standard scientific process of peer review, yet can be found in the databases of medical literature. This careful construction of a citable scientific record came in handy when the tobacco industry set out to attack early drafts of the EPA's report on secondhand smoke. Bero found that two-thirds of comments critical of the EPA report came from industry scientists, who drew heavily on industry-generated literature. The Tobacco Institute's own submission, for instance, cited 32 papers from symposia, but only seven peer-reviewed articles. As the industry has learned, however, research support doesn't guarantee that a scientist will go along with the company line. At least five members of an independent scientific advisory board that reviewed the EPA's 1993 secondhand smoke report had ties to industry research groups, either as advisers or grant recipients, including a scientist awarded a $1.2-million grant from Philip Morris during the review period. Yet the board unanimously agreed that passive smoking was a cancer risk. Public Persuasion In a public-relations campaign, scientific articles don't mean much if only scientists read them. The industry is bringing its perspective to a much wider audience, with the help of a few journalists. This became clear when we studied industry-generated material on secondhand smoke and looked over newspaper and magazine articles sympathetic to the industry's position. To read this material is to enter a house of mirrors that endlessly reflects the same set of opinions, voiced by the same few people, again and again. A person who saw nothing else could conclude that there were only four or five scientists in all of North America qualified to speak about secondhand smoke, all of them skeptical of its danger. You can see how this campaign works by tracing the public utterances of one such scientist, Gary Huber, a lung specialist at the University of Texas. Shook, Hardy & Bacon, the tobacco industry's longtime law firm, pays Huber's university to support his group's research on lung disease. Despite this, Huber told Consumer Reports, his views are his own. In 1991, Huber wrote an article for Consumers' Research (a small-circulation magazine not connected to Consumer Reports) in which he argued that the scientific evidence on the hazards of passive smoking is "shoddy and poorly conceived." In early 1993, Huber was prominently quoted in an article in Investor's Business Daily by Michael Fumento. Both Huber's and Fumento's articles became, in turn, sources for a series of opinion pieces written by journalist Jacob Sullum. In The Wall Street Journal and Forbes Media Critic, Sullum built on Fumento's arguments and quoted three of the same scientists Fumento quoted, including Huber. R.J. Reynolds reprinted Sullum's Wall Street Journal article nationwide in a full-page ad. The ad's headline: "If We Said It, You Might Not Believe It." Philip Morris bought full-page ads in major national publications for six straight days to reprint Sullum's longer Forbes Media Critic article. The industry's strategy has been effective. John Pierce, a researcher at the University of California, San Diego, checked the calls made to a statewide smokers' hotline immediately after the ads started appearing in print. Though the hotline was intended to give support to smokers who wanted to quit, the calls during that period were overwhelmingly accusatory. "We had a whole heap of people calling us, asking why we were misleading them," Pierce recalls. "There are all too many people willing to believe the industry when it says this thing's not really bad for you." Reading Between the Lines A persuasive newspaper ad that R.J. Reynolds published last spring offered to shed light on the secondhand smoke issue by considering how many "cigarette equivalents" nonsmokers are exposed to when they live or work with smokers. For instance, the ad said, a nonsmoker working among smoking colleagues inhales the equivalent of just 1 1/4 cigarettes a month. A waiter working full-time in a restaurant breathes just 2 cigarettes' worth. A reasonable person might wonder how that could be harmful. It might not be harmful, if it were the whole story. The numbers in the RJR ad look benign because the cigarette company counted only a part of the smoke that doesn't harm nonsmokers. The trick is that secondhand smoke is different from inhaled smoke. It consists mostly of the "sidestream" smoke that curls from the smoldering end of the cigarette when the smoker isn't inhaling. Sidestream smoke contains higher concentrations of certain toxic substances, including several cancer-causing ones, than mainstream smoke. The RJR ad focused on nicotine in the smoke. Good choice. Nicotine is addictive to active smokers, but it's not a carcinogen. What's more, it happens to be found in about the same concentrations in mainstream and sidestream smoke. A nonsmoker can breathe diluted, secondhand nicotine all month and, as the ad pointed out, only get a couple of cigarettes' worth. What if RJR had instead counted "cigarette equivalents" using the more carcinogenic components of sidestream smoke? Katharine Hammond, an environmental health expert at the University of California, Berkeley, considered the ad's hypothetical nonsmoker and added up a month's exposure. In testimony she submitted to the OSHA, Hammond found that: "In that same room, at that same time, the nonsmoker is getting as much benzene [a known human carcinogen] as a smoker gets in smoking six cigarettes, as much 4ABP, a known human carcinogen, as if smoking 17 cigarettes, and as much NDMA, the potent animal carcinogen, as one who smoked 75 cigarettes." Attacking the Science The heart of the cigarette makers' campaign appears to be their attack on the scientific methods used to measure the risk of secondhand smoke. In its advertising, its public statements and its lawsuit against the EPA, the industry argues that the agency "cherry-picked" data to reach a foregone conclusion and violated the rules of statistical analysis. That's a clever strategy. It takes advantage of the public's unfamiliarity with research methods and the common perception that one week's scientific report will be debunked the following week. To evaluate the arguments, CR consulted its own professional statisticians and also turned to Charles Hennekens and Julie Buring, epidemiologists at Harvard Medical School and coauthors of a leading epidemiology textbook. The tobacco industry argues that the EPA had no business pooling smaller studies, many failing the "statistical significance" test, into one large collection of data (meta-analysis). "They've combined studies as different as night and day, which is not an accepted way to do a meta-analysis," says Walker Merryman, vice president of the Tobacco Institute. In truth, the EPA made an effort to compare comparable studies. It sorted them by country or region, excluded the poorest-quality studies and then pooled data only within each geographical group. The pooled results for Greece, Hong Kong, Japan and the U.S. all showed statistically significant risk increases. The results from Western Europe and China, though positive, didn't reach significance. "Having a number of studies that show similar results but are not large enough individually to be statistically significant on their own is exactly the situation where meta-analysis is appropriate," Buring says. The Significance Level. When they analyze their data, most researchers try to set their "statistical significance" hurdle at 5 %. In everyday language, that means there is less than a 5 % probability that the results occurred by happenstance. However, the tobacco industry argues that the EPA lowered its hurdle to 10 % when it pooled the various studies. Journalist Jacob Sullum said it "in effect doubles the odds of being wrong." An industry scientific consultant called it a "confidence game." Here too, the EPA played fair. It did set a 5 % significance level. The agency used a standard statistical technique, called a one-tailed test, that allowed a 5 % chance of wrongly concluding that secondhand smoke increases the risk of cancer. This technique, taught in every introductory statistics course, is appropriate when, as in this case, there's already independent evidence a substance is harmful. What's more, when Hennekens and Buring analyzed pooled data from the 11 U.S. studies the EPA relied on most heavily, they found the data do meet the tougher standard the critics are demanding. Confounding Factors. Since epidemiologists can't control everything that happens in the lives of their subjects, they have to be wary of confounding factors, possible alternative causes for the results. Relatively small risks, like that from secondhand smoke, are especially vulnerable to confounding. The tobacco industry and its defenders have raised such a possibility. "There are numerous, and in many cases unaccounted for, factors which makes the whole process exceedingly difficult," Merryman says. "Since we're dealing with an issue of such magnitude, I think it's proper to insist they be accounted for." The critics have usually focused on diet or socioeconomic status, both of which have been linked to the incidence of cancer. If people exposed to secondhand smoke were more likely to be poor or to have poor diets, data could be muddied. In fact, the EPA considered possible confounding factors. Five of the studies it analyzed included information on diet. None of those five studies suggested that diet could account for the increased risk in people exposed to secondhand smoke. The studies the EPA relied on didn't record socioeconomic status, but the most recent study on secondhand smoke, published by Elizabeth Fontham, did. She found no effect on risk. Fontham also looked at diet and found that a diet high in fruits and vegetables did seem to protect people from lung cancer. But even after accounting for that, there was still a significant relationship between secondhand smoke and lung cancer. Since studies done in many countries with different cultures and habits all point to an elevated risk, confounding factors are not likely to be the explanation. The "Excluded" Studies. The industry has repeatedly implied that the EPA ignored two 1992 studies because they didn't support the agency's conclusions. Both were published during the seven-month period after the EPA report was written but before it was released. Neither study suggests that the EPA is wrong. A study conducted by University of South Florida researcher Heather Stockwell found that nonsmoking women married to smokers had a 60 % higher risk of lung cancer than women married to nonsmokers. The most highly exposed group in Stockwell's study, women exposed for 40 years or more, had a 130 % increase in risk. In the other study, Ross Brownson, then of the Missouri Department of Health, found no risk increase for all exposed women as a group. But the most highly exposed had a 30 % increase. Both the EPA and the industry have calculated, but not published, reanalyses that include all the new studies. The EPA says it still finds a statistically significant risk. R.J. Reynolds says it doesn't. Quitting Smoking Though the intended beneficiaries of smoking restrictions are non-smokers, smokers may benefit, too. As many studies have now confirmed, the imposition of smoking restrictions is enough to motivate some smokers to quit. Those who smoke at home should make heroic efforts to quit for the sake of their families, if not themselves. The declining rates of smoking in the U.S. show that people can quit. Unfortunately, teen-age smoking rates, after years of decline, seem to have leveled off and may even have begun growing again, especially among girls. As any heavy smoker who's tried to quit knows all too well, nicotine dependence is one of the toughest addictions to shake. Little wonder, since every puff provides not only a psychological reinforcement of the habit but also a satisfying micro-dose of nicotine. Nevertheless, about half of all Americans alive today who ever smoked have managed to quit. And the overwhelming majority of those who still smoke want to do likewise. The Best Ways To Quit Keep trying. Most smokers try to quit, and fail, several times before succeeding. There's some evidence that the more times a smoker has tried and failed to quit, the better the chance of success the next time. Go cold turkey. Most exsmokers did it that way. Cutting back gradually doesn't seem to work as well, probably because it continues to reinforce the habit. There's also evidence that addicted smokers who try to cut back end up inhaling more of the cigarettes they do smoke in order to keep their nicotine levels up. Get support. Especially for the most highly addicted smokers, support programs can make a crucial difference. These group programs generally feature a combination of lectures, behavioral management techniques and peer support. Low-cost or free programs are offered by many hospitals as well as local chapters of the American Lung Association (call 800-586-4872 for information) and the American Cancer Society (call 800-227-2345). Support at home is important, too. Nonsmokers: Tell your smoking friends and relatives how happy and proud you'd be if they tried to quit. If they make the effort, support them with praise, small favors and concrete strategies. If they fail, encourage them to try again. Consider the patch. Nicotine-replacement patches take the edge off the craving for cigarettes. Although not a magical solution, they've proven to be a helpful aid to other treatment methods for smokers who can't seem to quit on their own. One warning: There have been a few reports of heart attacks among people who continued to smoke while wearing the patches. The Bottom Line There's no question that all epidemiological studies have a built-in imprecision, Harvard's Julie Buring told us. That goes for epidemiological studies of secondhand smoke, too. "But when you see different investigators, using different definitions and study designs, all showing similar results, then you have to believe there's something going on." The case against secondhand smoke has reached that point. Short of conducting an impossible experiment (deliberately exposing thousands of people to secondhand smoke for decades, to see what happens), this is about as good as the human evidence on secondhand smoke is likely to get. When the results of epidemiological studies are combined with the laboratory studies, the abundant evidence that firsthand smoke causes cancer and the evidence for a dose-response relationship, the health implications are clear and the EPA's conclusion is inescapable: Secondhand smoke is a known human carcinogen. "If we didn't have the tobacco companies spending millions of dollars to confuse the facts, this issue would be an open-and-shut case," says Stanton Glantz, veteran tobacco researcher at the University of California, San Francisco. "The fact is that passive smoking causes lung cancer." Your Personal Risk? Since the amount of smoke inhaled appears related to the risk of disease, there probably is a minimal hazard from brief exposure. But steady doses of secondhand smoke at home or on the job aren't so benign. A nonsmoker's risk of dying from lung cancer, normally small, is increased slightly by living or working for years among people who smoke heavily. And although the individual risk is relatively small, the numbers add up to an issue of public health. Thousands of people in the U.S. may be dying or made sick every year from other people's smoking. James Repace and Alfred Lowrey, statistical researchers who study the effects of secondhand smoke, have concluded that a lifetime increase in lung-cancer risk of 1 in 1,000 could be caused by long-term occupational exposure to air with more than 6.8 micrograms of nicotine per cubic meter of air. The EPA found 19 reports of measurements of nicotine levels in enclosed spaces where people smoked. Levels in homes of smokers had averages that ranged, from study to study, between 2 and about 11 micrograms. In offices, the range of averages was about 1 to 13 micrograms. Restaurants were even smokier, with averages between about 6 and 18 micrograms. The Profit Motive If secondhand tobacco smoke were not connected to the profits of a powerful industry, Consumer Reports doubts there would be much argument about drastically restricting people's exposure to it. The lifetime added risk of developing lung cancer from prolonged exposure to secondhand smoke is roughly 1 in 1,000. That's 1,000 times greater than the one-in-a-million lifetime cancer risk considered unacceptable for many other environmental contaminants. Even in small doses, it can be an uncomfortable irritant, at the very least. Stepping up the Pressure In response to the data, the tobacco industry has accelerated its campaign against public smoking restrictions. It has sued in federal court in an effort to overturn the EPA's decision about secondhand smoke. Last year, five companies together laid out nearly $18 million in an unsuccessful effort to persuade California voters to approve a smoking-control law that would have invalidated stronger state and local restrictions. The 1994 elections greatly improved the tobacco industry's legislative prospects. Out as chairman of the House Subcommittee on Health and Environment is Democrat Henry Waxman of California. His hearings last year produced the widely seen image of tobacco-company chiefs swearing they didn't think cigarettes were addictive. His likely replacement is Republican Thomas Bliley. The major employer in Bliley's Virginia district is Philip Morris, and Bliley has already said, "I don't think we need any more legislation concerning tobacco." Consumer Reports disagrees. Nonsmokers' Rights Consumer Reports believes nonsmokers have a right to breathe smoke-free air. We have long favored restrictions on where people may smoke. The medical evidence makes it imperative to impose such limits. In particular, we support measures to keep smoke out of the workplace, not just offices and factories but also restaurants, stores and public transportation, because of the risk to the millions of Americans who work there, too. As this report was published, OSHA was considering nationwide rules that would, in effect, ban smoking on the job except in specially ventilated areas. Consumer Reports supports OSHA's efforts to limit workplace smoking to certain ventilated rooms. OSHA calculates that over the next 45 years a workplace smoking ban would eliminate between 5,500 and 32,500 lung-cancer deaths and 98,000 to 578,000 deaths from heart disease. (The variation comes from uncertainty about current levels of exposure to secondhand smoke.) Control of smoke is one of the great public-health bargains. Getting rid of workplace smoke requires posting signs, putting a few chairs and an ashtray outdoors, or putting an appropriate ventilation fan into a special smoking room, an improvement that OSHA estimates would cost $4,000 per building. In contrast, the bill for removing asbestos from a commercial building averages $300,000. Locally Available Reprints Date: Friday, April 21, 2000 Report Confirms Damage of Secondhand Smoke, Marketing Aimed at Children Copies of the 1995 Consumer Reports articles on secondhand smoke and youth are once again available. Two versions are available in a new color: One version has a man on the cover and emphasizes and "secondhand smoke" dominates the cover. He is being exposed to secondhand smoke. The other version has a girl smoking on the cover and emphasizes both secondhand smoke and teenage smoking. Both versions are identical inside and contain two well-written articles on the issue. More than 40,000 of these reprints have been distributed. You can order copies form ASSIST through Bernie at 303/692-2511. Copies may also be obtained from GASP for 25¢ each plus shipping and handling (call us at 303-444-9799 for an order form). The articles are reprinted in their entirety with permission from Consumers Union. Key points from the Consumer Reports articles Study on secondhand smoke (Consumer Reports, January 1995): Contains a balanced analyses about the evidence about secondhand smoke, including the risks getting lung cancer and heart disease from secondhand smoke. Examines and rebuts the tobacco industry criticisms of the scientific evidence. Concurs with the Environmental Protection Agency decision to classify secondhand smoke as a known human carcinogen in 1993, asserts that the decision was unanimous, and shows how the tobacco industry has been trying to discredit the EPA report. Tells how the tobacco industry has tried to spread doubt and discredit the scientific research on secondhand smoke. Says the case against secondhand smoke has reached the point where there can be no doubt about the scientific evidence. Recommends limiting smoking in public places, restaurants, and the workplace. Study on teen smoking: (Consumer Reports, March 1995): Three thousand kids start smoking in the U.S. every day. Teen tobacco usage is on the rise, while adult tobacco usage is down. How tobacco advertising influences kids to buy and use tobacco by: Taking advantage of false perception that everyone smokes. Using images to make smoking look socially acceptable. Promoting smoking as a form of personal independence. Creating the impression that tobacco can help control weight (Virginia Slims) Using value-added promotions to entice kids. Why smokeless tobacco is a serious cancer threat. Reveals how teens easily purchase tobacco despite restrictions on tobacco sales to minors. Provides suggestions on helping teens avoid tobacco. Recommends restricting tobacco sales to minors, eliminating or reducing tobacco advertising, and increasing tobacco taxes. Copyright Notice © 1995 by Consumers Union of U.S., Inc., Yonkers, NY 10703. Excerpted by permission for educational purposes from the January 1995 issue of Consumer Reports. No downloading, photocopying or re-transmitting permitted. To subscribe or to order a copy of the complete article for $3.00 each from the following address or call 1-800-234-1645. You can visit Consumers Union at http://www.ConsumerReports.org/. 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