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2000 Surgeon General's Report—Reducing Tobacco Use

Clean Indoor Air Regulations

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Highlights

Minimal Clinical Interventions

• As reported in 1992 by the U.S. Environmental Protection Agency (EPA), exposure to tobacco smoke in the environment can cause lung cancer in adult nonsmokers. Environmental tobacco smoke (ETS) also has been linked to an increased risk of heart disease among nonsmokers.
• ETS causes about 3,000 lung cancer deaths annually among adult nonsmokers.
• In 1997, the California EPA concluded that ETS causes coronary heart disease and death in nonsmokers. Scientific studies have estimated that ETS accounts for as many as 62,000 deaths from coronary heart disease annually in the United States.
• The 1992 EPA report also concluded that ETS causes serious respiratory problems in children, such as greater number and severity of asthma attacks and lower respiratory tract infections. ETS exposure increases children’s risk for sudden infant death syndrome (SIDS) and middle ear infections as well.
• Each year ETS causes 150,000–300,000 lower respiratory tract infections, such as pneumonia and bronchitis, in children.
• In a large U.S. study, maternal exposure during pregnancy and postnatal exposure of the newborn to ETS increased the risk for SIDS.
• Comparative risk studies performed by the EPA have consistently found ETS to be a risk to public health. ETS is classified as a group A carcinogen (known to cause cancer in humans) under the EPA’s carcinogen assessment guidelines.
• Several studies have documented the widespread exposure of ETS among nonsmoking adults and children in the United States. Testing nonsmokers’ blood for the presence of cotinine, a chemical produced when the body metabolizes nicotine, shows that nearly 9 out of 10 nonsmoking Americans (88%) are exposed to ETS.
• A 1988 National Health Interview Survey reported that an estimated 37% of the 79.2 million nonsmoking U.S. workers were employed in places that permitted smoking in designated areas, and that 59% of these workers experienced moderate or great discomfort from ETS exposure in the workplace.
• Under common law (laws based on court decisions rather than government laws and regulations), employers must provide a work environment that is reasonably free of recognized hazards. Courts have ruled that common–law duty requires employers to provide nonsmoking employees protection from the proven health hazards of ETS exposure.
• The Occupational Safety and Health Administration is considering regulations that would either prohibit smoking in all workplaces or limit it to separately ventilated areas.
• The federal government has instituted increasingly stringent regulations on smoking in its own facilities. On August 9, 1997, President Clinton signed an Executive Order declaring that Executive Branch federal worksites be smoke-free, thereby protecting nonsmoking federal employees and thousands of citizens who visit federal facilities from the dangers of ETS.
• The Pro-Children’s Act of 1994 (Public Law 103–227, secs. 1041–1044) prohibits smoking in facilities where federally funded children’s services are provided on a regular or routine basis.
• As of December 31, 1999, at least some degree of smoke-free indoor air laws were present in 45 states and the District of Columbia. These laws vary widely, from  limited smoking restrictions on public transportation to comprehensive restrictions in worksites and public places.
• Twenty states and the District of Columbia limit smoking in private worksites. Of these states, only one (California) meets the nation’s Healthy People 2010 objective to eliminate exposure to ETS by either banning indoor smoking or limiting it to separately ventilated areas.
• Forty-one states and the District of Columbia have laws restricting smoking in state government worksites, but only 13 of these states meet the nation’s Healthy People 2010 objective.
• Thirty-one states have laws that regulate smoking in restaurants; of these, only Utah and Vermont completely prohibit smoking in restaurants. California requires either a no smoking area or separate ventilation for smoking areas.

Additional Benefits

• An additional benefit of clean indoor air regulations may contribute to a reduction in smoking prevalence among workers and the general public. Studies have found that moderate or extensive laws for clean indoor air are associated with a lower smoking prevalence and higher quit rates.
• The majority of smokers support smoke-free hospitals. Smokers and nonsmokers were in favor of smoke-free workplace six months after a smoke-free policy was implemented.
• Employers are likely to save money by implementing policies for smoke-free workplaces. Savings include costs associated with such things as fire risk, damage to property and furnishings, cleaning, workers’ compensation, disability, retirement, injuries, and life insurance. Cost savings were estimated at $1,000 per smoking employee based on 1988 dollars.
• The EPA estimates a nationwide, comprehensive policy on clean indoor air would save $4 billion to $8 billion per year in building operations and maintenance costs.

Establishing Public Policy

• Involuntary exposure to ETS remains a common public health hazard that is entirely preventable by adopting appropriate regulatory policies.
• To fight the establishment of such policies, the tobacco industry tries to shift the focus from the science-based evidence on the health hazards of ETS to the controversial social issue of personal freedom. The industry has lobbied extensively against legislation to restrict smoking, and has supported the passage of state laws that preempt stronger local ordinances. (Preemptive legislation is defined as legislation that prevents a local jurisdiction from enacting laws more stringent than, or at a variance with, the state law.)
• A case study conducted in six states found that the existence of an organized smoking prevention coalition among local citizens was a key determinant in successfully enacting clean indoor air legislation.
• Smokefree environments are the most effective method for reducing ETS exposure. Healthy People 2010 objectives address this issue and seek optimal protection of nonsmokers through policies, regulations, and laws requiring smoke-free environments in all schools, work sites, and public places.

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