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Chapter 7

She calls it the "grand gesture of smoking."

"Smokers do it unconsciously," she explains, throwing her head back and exhaling upward with a flourish. "It's a very unconscious movement, dragging it, and then blowing it up, and throwing your head back." She mimics a silent-movie star, blowing imaginary smoke into the air.

"People who don't smoke make fun of the glamour. To a real smoker, there is no glamour. It's just a thing. It's like eating and drinking water. It's just there. It's time to go have a cigarette."

She shrugs and picks up a cigarette and lighter. It's time to go have a cigarette.

"I try to be a considerate smoker," she mentions as we walk outside. "I don't like to smoke in my house, and I don't allow smoking in my house. I don't like the furniture, and the drapes, and the carpet and the clothes smelling like smoke. The only smoking at my house is on the front porch and the back porch."

Sometimes, to their condemnation, some people smoke on her back porch with the back door open, not noticing which way the wind is blowing. If it blows into the house and she can smell it at the other end of the house, she gets irritated, she says.

As the city winds shift, she moves from one side of me to the other. She is a downwind smoker.

"I try to keep the smoke away from the people who don't smoke. Like . . . the wind is blowing this way right now, so, technically I should be on the other side of you." She moves around me again.

"I try to be really aware of when somebody's walking by and the wind is blowing toward them, so that I don't take a drag on my cigarette until they're past.

"I think it's really funny when I'm standing there, just holding a cigarette, and the winds are blowing from west to east, and somebody who's walking from east to west passes me, so they're upwind of me, and I have a drag, and they go [cough] [cough] like that. They can't even smell it, so what is their problem? The wind is, like, 20 miles an hour the other way. I find things like that amusing."

She particularly doesn't like it when other smokers blow smoke in her face.

The Accidental Smoker

The nonsmoking section was full by the time the woman got a seat on the plane. In the 1970s, before U.S. airlines went smoke-free on domestic flights, it was still possible for a nonsmoker to be stuck in the middle of a smoking section. She resigned herself to what she knew would be several hours of discomfort and buckled herself into her seat.

As she noticed cigarette packs bulging the shirt pockets of the men seated around her, she thought back to her childhood, when her father's boss would occasionally come over to spend the day at their house. He would chain-smoke, filling their small home with an odor that her mother would spend days trying to air out of the draperies and carpets. They had never dared ask him not to smoke, because he was the boss.

And she thought back to the job she had left two years earlier, where she had worked only a few feet away from a chain-smoker, eight hours a day. She had developed asthma and, on her doctor's advice, had quit that job to take another. Ever since then, the smell of cigarette smoke had made her queasy. It also made her cough. She would rather have been sentenced to cleaning latrines than to spending the afternoon in the smoking section of an airplane. She mentally chided herself for not reserving a seat in the nonsmoking section.

Once the flight was airborne, the man next to her pulled out his pack of cigarettes and tapped one free.

"Do you mind if I smoke?" he asked, almost as an afterthought.

"Not if you don't mind if I get sick," she answered.

This small encounter, now anachronistic in many social settings, typifies the war that erupts repeatedly over involuntary exposure to tobacco smoke. Smokers claim a right to use their tobacco, sometimes without seeming to be aware of just how noxious others might find their smoking to be. Those on the other side want to avoid exposure to environmental tobacco smoke at almost any cost. Compromise can be difficult to achieve.

The facts, as we now know them, are these:

What It Is and Does

The terminology associated with this phenomenon can be confusing. The most descriptive overall term is environmental tobacco smoke (or ETS), which includes sidestream smoke that comes from the burning cigarette (for example, between puffs) and mainstream smoke that is exhaled by a smoker. The term passive smoking refers to inhalation of tobacco smoke in the air, and is synonymous with secondhand smoking. Most environmental tobacco smoke consists of sidestream smoke. Although mainstream and sidestream smoke differ, "active and passive smokers inhale the same toxins and are thus likely to suffer from the same health effects," according to German tobacco expert Friedrich J. Wiebel. He listed the immediate effects of environmental tobacco smoke as the following, in a 1997 review:

The chronic effects can include the following:

Studies reporting relationships between these diseases, particularly lung cancer, and passive exposure to tobacco smoke have not gone without criticism. As with any area of scientific inquiry, the perfect study remains yet to be done; some epidemiological studies, in particular, are vulnerable to criticism because of inadequate methods and analyses. Despite these acknowledged limitations, Wiebel concluded, "In the final analysis, it is the total weight of the toxicological and epidemiological evidence which gives confidence to the conclusion that ETS is a human lung carcinogen."


The use of tobacco entails considerable health risk. Many volumes have been written to document this assertion; in fact, no book can be current about the subject, because new announcements of tobacco's health risks are published continually in medical journals. The risks, detailed in literally thousands of scientific articles covering a broad range of disciplines, have been enumerated for decades and continue to be explored. The general public is probably best acquainted with the risk of cancer, since the earliest public declarations about tobacco's effects focused on lung cancer. However, tobacco-related cardiovascular disease is an even greater cause of death and disease than tobacco-related cancer. The list of health problems that are caused or exacerbated by tobacco is lengthy; it includes the following:

The health hazards of involuntary exposure began to be documented years later than those of active exposure. Even so, more than 12 years ago the U.S. government enumerated problems with environmental exposure to tobacco smoke in its 1986 Surgeon General's report, The Health Consequences of Involuntary Smoking. Since the 1986 publication of that report, the U.S. government has continued to endorse reports detailing the hazards of environmental exposure. A 1992 report, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders, from the U.S. Environmental Protection Agency (EPA) continued the theme of the earlier report. It explained that determinations of the potential associations between environmental tobacco smoke and lung cancer use a "weight-of-evidence" analytic approach, in accordance with U.S. standards for assessing carcinogen risk, or, in other words, the risk that a substance poses for causing cancer. This approach takes into account animal studies and measurements of the human uptake of tobacco smoke components, in conjunction with human data. It "allows a hazard identification to be made with a high degree of certainty," the report concluded. In fact, it added, the total public health impact from environmental tobacco smoke could be greater than the report indicated.

In 1997, the California Environmental Protection Agency released what Business Week magazine called "the most devastating report yet" on the dangers of environmental tobacco smoke. The California report indicated that environmental exposure caused as many as 62,000 deaths from heart disease, 2,700 cases of sudden infant death, and 2,600 new cases of asthma each year. It declared that secondhand smoke increased the risk of cervical cancer and spontaneous abortions. It identified more than 50 tobacco compounds as carcinogens, with 6 also listed as sources of reproductive or developmental problems. Business Week writers Paul Raeburn and Gail DeGeorge commented, "[T]he powerful evidence in the new reports damning secondhand smoke suggests that, outside the courtroom, there is nothing left to debate."

New findings about serious health consequences of both voluntary and involuntary exposure are published so continuously that it is difficult to stay current about them. A comprehensive 1997 book on the health consequences of smoking ( Cigarettes: What the Warning Label Doesn't Tell You) had no sooner been published than scientists announced several newly documented hazards associated with smoking. For example, a September 1997 report in the Journal of the National Cancer Institute stated that even those who had quit smoking were at increased risk of some cancers as much as 30 years later. Researchers Marilie D. Gammon and colleagues of the Columbia School of Public Health in New York found that as many as 40 percent of cancers of the esophagus and stomach could be tied to cigarette smoking. Their study of more than 1,200 subjects, 554 of them cancer patients, indicated that both current and former smokers more than doubled their risk of adenocarcinoma, a type of esophageal or stomach cancer. Former smokers' risk was decreased only if they had stopped smoking more than 30 years before. The authors stated that the recent increase in adenocarcinoma among older persons could be due to the increase in cigarette smoking earlier in the century.

Scientists and physicians feared that the results might discourage smokers from quitting, since they might assume that the damage had already been done. They emphasized the necessity of continuing to reduce risk by quitting smoking. Also, since tobacco was not responsible for all such cancers, other elements such as diet, medications, and other medical conditions also present an established risk.


two-thirds those in U.S. in 1991 who accepted cigarette-pack warning labels as legal protection for tobacco companies
51% those in U.S. in 1996 who accepted warning labels as legal protection for tobacco companies
62% current U.S. smokers who accept warning labels as legal protection for tobacco companies
52% former U.S. smokers who accept warning labels as legal protection for tobacco companies
46% U.S. never-smokers who accept warning labels as legal protection for tobacco companies
62% those under age 30 in U.S. who accept warning labels as legal protection for tobacco companies
43% those age 65 and older in U.S. who accept warning labels as legal protection for tobacco companies
(Klein, 1997.)

Similar reports emerged in the medical research literature relating not only to the risks of smoking itself, but to involuntary exposure. A sobering announcement came in January 1998, when biostatistician George Howard and associates at the University of North Carolina at Chapel Hill reported that not only did smoking result in heightened risk of atherosclerosis among smokers, but the risk was also increased significantly for nonsmokers exposed to environmental smoke. The investigators, whose findings were published in The Journal of the American Medical Association, wrote: "These data represent the first report, to our knowledge, from a large population-based study of the impact of active smoking and exposure to environmental tobacco smoke on the progression of atherosclerosis." They noted that active smoking played "a major role in the progression of atherosclerosis, as did the duration of smoking measured by pack-years of exposure." They added, "The impact of exposure to environmental tobacco smoke on atherosclerosis . . . was also surprisingly large, increasing the progression rate by 11 percent above those not so exposed."

This report came about six months after the American Heart Association's journal Circulation published an article indicating that regular exposure to environmental smoke almost doubled the risk of heart disease. A Harvard University research team led by Ichiro Kawachi found in a 10-year study of 32,000 nurses that those with regular exposure to environmental smoke had a 91 percent greater chance of developing heart disease.

Also published in 1997 was a report from the Australian federal government aimed at reducing the risks from passive smoking. Australia's National Health and Medical Research Council had urged governments and employers to reduce the health risks caused by exposure to environmental tobacco smoke, citing "compelling evidence" that such smoke is hazardous. The NHMRC recited these conclusions:

The report followed a legal struggle between the tobacco industry and the NHMRC the previous year, in which legal technicalities forced the council to drop formal recommendations for new health regulations. Instead, the council issued the report, which reviewed more than 400 studies from around the world.

Give the Kid a Break

12 — 19 weeks period of gestation in which nicotine binding sites increase in the human fetal brain, a process altered by contact with nicotine
30 minutes time at which maximum reduction in fetal "breathing" occurs, following mother's use of nicotine
90 minutes point at which fetal breathing recovers to normal rates
four times increased likelihood that the son of a mother who smokes during pregnancy will become delinquent
20% pregnant women who continue to smoke (U.S.)
25% pregnant women who succeed at quitting smoking (U.S.)
12% pregnant women who quit during the second trimester (U.S.)
almost none decline in smoking prevalence of women of reproductive age in 33 U.S. states, 1990-1993
probably none number of U.S. states likely to meet the "Year 2000" goal of 12% smoking among reproductive-age women

Challenges and Responses

Scientific findings about the risks of environmental tobacco smoke were questioned in a 1995 report from the Congressional Research Service, a division of the Library of Congress. Economists C. Stephen Redhead and Richard E. Rowberg concluded that the statistics from environmental tobacco studies did not support the conclusion that passive smoking involved substantial health effects. They stated, "[E]ven when overall risk is considered, it is very small risk and is not statistically significant." They determined that nonsmokers exposed to low levels of smoke had little or no additional relative risk of lung cancer because of their exposure. They charged that epidemiological studies were plagued with "misclassification and recall bias."

Opposition to the Congressional Research Service report was quick to arise. The debates, like many others of recent years, emerged on the Internet, where World Wide Web sites from both sides took each other to task. A group called California Smoke Free Cities, funded through the state Department of Health Services' allocation of tobacco tax money, explained that the Congressional Research Service determination was made with a "threshold" approach to cancer risk. The threshold theory holds that below a certain threshold of exposure, there is no risk of lung cancer. Public health authorities have not accepted this theory, but it has been employed by the tobacco industry. With this theory, a researcher estimates fewer potential cases of lung cancer deaths in relation to known risks than would be possible by using more traditional means.

The goal of the Congressional Research Service report, however, apparently was not to take sides either with the tobacco industry or with those in the medical community who had declared environmental tobacco smoke to be hazardous. The report was not in direct competition with the 1992 EPA report, which, unlike the Congressional Research Service report, underwent extensive scrutiny in peer review from independent scientists. The EPA report, unlike the Congressional Research Service report, also received considerable support from federal agencies and health-related organizations. Actually, the Congressional Research Service report might have gone largely unnoticed except that the National Smokers Alliance, an organization related to tobacco interests, used the report in an effort to amend a California law requiring smoke-free work environments.

Innocent Bystanders

3,000—5,000 U.S. people dying anually from lung cancer associated with involuntary exposure to tobacco (secondhand smoke)
30,000—50,000 U.S. people dying anually from heart disease associated with involuntary exposure to tobacco
double extent to which secondhand smoke increases the risk of heart disease among women
25% U.S. children's bed confinement days attributable to secondhand smoke
25% U.S. children's school absence days attributable to secondhand smoke
24% nonsmoking parents of an asthmatic child failing to attend an asthma education program in one Minnesota community
42% parents in one-smoker households failing to attend the same program
78% parents in two-or-more-smoker households failing to attend the same program

The Congressional Research Service report was not the first challenge to the official U.S. government stance that the public health community's concerns about environmental smoke are warranted. A 1995 exchange in the journal Risk Analysis also chronicled the arguments on both sides. In that debate, Gio B. Gori took issue with the 1992 EPA report's conclusions that environmental tobacco smoke causes cancer and increases the risk of respiratory disorders. At issue was a question of whether environmental smoke differs substantively from what a smoker inhales. In response, Jennifer Jinot and Steven Bayard of the EPA argued that the agency's conclusions were based on "a comprehensive analysis of the total weight of evidence, in accordance with the Agency's risk assessment guidelines." They stated that the EPA assessment had been subjected to public review twice, and to review by an independent scientific panel of 18 experts.

The primary argument was whether or not environmental tobacco smoke is related to lung cancer. Also at issue were respiratory effects. As arguments in favor of asserting that environmental smoke is hazardous, Jinot and Bayard cited these findings:

Jinot and Bayard commented: "The EPA analysis concludes that the overall consistency of positive responses in numerous studies of different design from many countries, consistently positive and statistically significant exposure-response relationships, and consistently higher risks in the highest exposure groups provide sufficient evidence that the risks of both lung cancer and noncancer respiratory effects from ETS exposure are real and cannot be ignored."

The debate continues with vehemence in many arenas. In September 1997, columnist Robert J. Samuelson complained in The Washington Post that in all of the sensitivity directed toward minorities recently, one minority had been overlooked: smokers. Samuelson argued, "The debate over cigarettes has been framed as if smokers are the unwitting victims of the tobacco industry." According to Samuelson, smokers are treated as if they "lack free will and, therefore, their apparent desires, opinions and interests don't count." His article also called the health risks from environmental tobacco smoke into question.

Samuelson's column drew sharp response from former U.S. Surgeon General C. Everett Koop, viewed by many as the guardian of the nation's health for nearly two decades. "As I understand it," Koop began, Samuelson was claiming that respected newspapers and educational institutions "have been duped by a group of anti-smoking zealots and public health loonies." He criticized Samuelson's lack of data to support his counterclaims about environmental tobacco smoke. "I agree that smokers have rights," Koop stated, "but the right to harm others is not one of them."

Going Smoke-Free

Just what happens when smokers are forced to go smoke-free at their workplace can be a surprise to all involved. In 1989, the author of this book and Maxine Stitzer at the Johns Hopkins University School of Medicine ran a study investigating that question as the Hopkins medical institutions converted to smoke-free workplaces. As the ban was being implemented at what was then the Francis Scott Key Medical Center, we followed 34 smokers who were no longer allowed to smoke at their work stations. Before the ban, some of them found places in their work areas where they thought they could get away with smoking undetected, such as closets or unused rooms. One smoker, fearful of any restrictions, threatened to set up her office outside her window on an adjoining rooftop, where she could smoke. (It was easily accessible through a window, she explained.)

The implementation of the smoking ban brought a sudden decrease in the amount of tobacco they consumed. However, few of those in the study followed through with their threats to smoke in secret places inside the buildings. One worker explained that once the time came, it simply seemed like too much bother. The smoker who had considered setting up an open-air rooftop office perch found that she was able to cope, despite some discomfort. Tobacco exposure, as measured through breath carbon monoxide and through nicotine levels in smokers' saliva, declined. Overall tobacco exposure, as measured by the nicotine metabolite cotinine, decreased by 15 percent, but the decline was not statistically significant. Smokers used an average of four fewer cigarettes per day. The smokers we assessed experienced abstinence effects consistent with their reduced exposure to tobacco, including cravings for cigarettes, urges to smoke, difficulty concentrating, increased eating, and depression symptoms.

To determine whether the smokers engaged in compensatory smoking, we not only measured biological indicators of exposure to nicotine, but also counted and weighed their cigarette butts, which they dutifully collected in little plastic bags every day. They kept butts smoked at different times of the day separated in different plastic bags, so that we could see whether they smoked more in the mornings or before work (some worked on night shifts). This allowed us to determine whether their smoking patterns shifted, or whether they otherwise compensated for not being able to smoke as they worked.

We desiccated the butts to a consistent 20 percent humidity level, to compensate for the Baltimore, Maryland, summertime humidity that frequently reached 80 and 90 percent. We then counted, weighed, and measured the length of the butts; cigarette butt weight was an indirect measure of the intensity of smoking. Butt length, like butt weight, also indicated the amount of material left unsmoked in the cigarette. Butt length also provided an indirect measure of toxicity, since tar and carbon monoxide delivery increase logarithmically as a cigarette is smoked to a shorter butt length.


204,544 number of cigarette butts picked up in 1995 California statewide beach cleanup
17% California population that smokes
about half proportion of California beach debris consisting of cigarette butts
foam plastic second most common California beach debris item
junk food wrappers third most common California beach debris item
about 8,000 yearly reports of toxic exposure to tobacco products among children younger than age 6 in the U.S.
146 reports of nicotine poisoning by children under age 6 in Rhode Island in an 18-month period
high likelihood that cases of cigarette-butt ingestion by children are underreported
high likelihood that a nicotine-poisoned child lived in a home where adults used tobacco in the presence of children

We found that the smokers did not seem to compensate to an appreciable degree for the smoking restrictions. They did not smoke the butts down farther and did not load up on nicotine to any noticeable extent before coming to work. Instead, they reduced their overall exposure and, for those hours at work, put up with the discomfort of abstinence symptoms. We had anticipated that many of the participants would want to use the workplace restrictions as a reason for quitting smoking, particularly since the hospital offered smoking cessation help for any employees who wanted to quit. To our surprise, not one of our study participants quit smoking as the ban was implemented, or for six months following.

Bans Roll On

up to 25% extent to which a workplace smoking ban can reduce smoking
9% percent of workers, unable to smoke at work, expressing a strong need to smoke at work
71% percent of workers, unable to smoke at work, expressing a mild or occasional need to smoke at work

Another surprise came when we sought a comparison group of smokers who were still allowed to smoke at their hospital worksites. As we called hospitals within a radius of about a hundred miles, we found that all either had implemented or would soon implement smoking restrictions. When we had started our study at Francis Scott Key, few hospitals in the area had smoking restrictions; within just a few months, virtually all of them either were restricted or were soon to be restricted. The policy changes had come so quickly that to populate our comparison group, we had to look at work settings other than hospitals to find smokers who weren't undergoing smoking restrictions.


Some tobacco-control experts have a dream that someday the world will be free of tobacco. They know it is not a realistic dream. Some smokers also have a dream that someday the nonsmoking world will quit hassling them about their smoking. Imposing draconian restrictions on smokers has been known to trigger backlash among some opponents. For instance, the 1998 implementation of a smoking ban in bars in California was "the last straw" for many smokers. Smoking already had been banned in California restaurants for some time; bars were among the last places that smokers could smoke in public settings.

California's bar ban went into effect at midnight, January 1, 1998. Many smokers celebrating in California bars that night did not compliantly extinguish their cigarettes and go on about their merrymaking. Instead, some bars set out cash jars so that customers could contribute to paying the fees for those who would be fined for violating the prohibition. Many smokers just kept smoking, with the full blessing of the proprietors of the establishment. Enforcement was sporadic, at best. Some bar owners set up separate smoking areas where customers could light up but employees could not go. Within weeks, the lower house of the California legislature, the Assembly, considered rescinding the ban, which even some nonsmokers saw as being too restrictive. A Californian supporting the ban remarked on a radio program that the Assembly was attempting to respond to its constituency on the issue with amazing speed; if only it would respond that quickly on issues such as health care, he noted dryly.

Californians' responses to the state's groundbreaking smoking restrictions reflected either love or hate, but rarely anything in between. San Francisco Examiner columnist Rob Morse wrote a column entitled "Emission Control Problems," in which he described imaginary restrictions on smoking in cars (which, by the way, were never proposed). Those caught smoking in their cars would have their drivers' licenses revoked and returned the next year "with an even worse picture." As if that weren't dire enough, he offered the prediction that automobile ashtrays would be required to be filled with change, not with cigarette ashes, and would be known as "cashtrays." He concluded, "Now about those smoking and no-smoking lanes . . ."

The battle lines over smoking restrictions have been drawn in many places and many venues, such as these:

There may be no simple resolution to the conflict between smokers and those exposed to their smoke. Pro-tobacco rhetoric notwithstanding, the health hazards of environmental exposure to tobacco smoke are accepted widely throughout the scientific and medical communities. And even if tobacco smoke weren't toxic, many nonsmokers (and some smokers) find it so noxious that they prefer that it be restricted, toxic or not.

On Risk

Risk analysis specialist W. Kip Viscusi noted in 1992 that "Risk taking is an inescapable feature of our lives." He characterized smoking as "an individual risk-taking activity," independent of involuntary exposure to secondhand smoke. "If these choices are informed and have no adverse effects on society, there would be no efficiency rationale for regulating this behavior."

However, the choices smokers make do affect others. Not all smokers use tobacco in a way that preserves others' right to clean air. As Viscusi explained, "Smokers may take some . . . risks into account, particularly for family members, but are not likely to undertake actions that are fully optimal from a society perspective."

Hence comes the need for government regulations protecting those who otherwise are placed at risk by others' use of tobacco. In civilized society, as adults we do not inflict our detritus on others. Our cars have mufflers and smog-control devices. Our waste-water goes into a sewage system. We cough behind our hands. We do not double-dip our potato chips. We do not spit in others' food, or anywhere else that others might be, for that matter.

And we should not expect others in our immediate vicinity to breathe our smoke.

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Copyright 1998 National Academy Press