THE HEALTH . 1 I CONSEQUENCES OF INVOLUNTARY SMOKING a report of the Surgeon General U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES P&k Health Smvke `.rtStCstlAs"Or*t.LI*.ND*"UI1ot.",(t~ ".s*l*GI"* DL mie, MC I 5 1986 The mnorable George Bush President of the Senetc W..hington. D.C. 20510 Desr Mr. President: It is my pleasure to transmit to the Congress the 1986 Surgeon Gener.1'. Report on the halt? consequence. of smking, . . mandated by Section g(s) of the Public Re.lth Cxgsrette S-king Act of 1969. me "e.lth Consequence* of involunt.ry Smking The current volume, entitled , exuine. the scientific evidence on the he.lth effect. re."lttng from mn.mker exposure to envirollaenr.1 tob.cc" snake. The issue of whether or mt tob.cco slake is c.rcinogeaic for humans was conclusively resolved mre thss 20 ye.=. *go when the first report on *staking *ad heslth w.. issued in 1964. Eased on the c"rrent report, the judgment c.n 11)y be tude that exposure to envim-nt.1 tob.cco s-kc csn E.".c disesse, including lung cancer, in mnstmkers. It is *la clear th.t simple .ep.r.cioa of smkers snd mns~ker. within the ..Y sirspsce uy reduce but canmt elimin.te mnsmker exposure to envirorucnt.1 tobacco slake. Ihe report .lw review. *II extensive body of evidence which e.t.bli.he. .O incressed risk of reapir.tory illness snd reduced lung function in infsnt. .nd very y~"ng children of p.rent. rbD .oke. Ihi. effect is ~)re pmmuaced if both pxent. sake than if only one p.rent sakes. A. . phy.ici.n. I believe th.t p.reot. should refr.in from -king *round s-11 children both s. . r.n. of protecting their children'. heslth and to set . pd o rqle for the child. Today, only 30 percent of the adult populstion in the United gt.te. .re *mker.-the 1are.C level of soking in the country since World Ysr II, reflecting th.t the grest msjority of the populstion h.. never mked or hr. *"cce**f"lly quit. Accompsnying this decline in over.11 prevslence of cigsrette smking h.. been sn Lcrersed cancera for protecting the he.lth .nd well being of mnsmxker., s. evidenced by the number of lr. and reyl.tion. restricting soking in public plsces. Todsy, 40 gtste. snd the District of Dlubi. hsve enacted some fotn of legislstion to restrict swking in public. Increasingly, these lr. pertsin to protecting mnswkcrs in uny different setting., including the varkplsce. B..ed on the evidence presented in this report. the choice to slake .hD"ld n"t interfere with the mn.aDker'. choice for sn environment free of tob.cco .aDke. Sincerely, . &gwhNtQ m% Otis B. gown, M.D. secretary enc1o.ure DEL 5 The ibnorable Thomas P. O'Neill, or. Speaker of the H3u.e of Representatives Washington, D.C. 20515 Oear Hr. Speaker: It is my pleasure co rransmit to the Congress the 1986 Surgeon General's Report an the health consequences of sroking, . . mandated by Section B(a) of the Public Health Cigarette Smklng Act of 1969. The current volume. entitled The Health Consequences of Involuntary Swking, examines the ocieotific evidence on the health effects resulting from nonsmoker exposure to environmental tobacco smoke. The issue of whether or mt tobscco awke is csrcimgenic for humans ~88 conclusively resolved m)re thsn 20 yesrs .go when the first report on smking and heslth YBB issued in 1964. Based on the current report. the judgment c.n now be made chat exposure to environmental tobscco sswke csn cause disease. including lung cancer, in mnsmkers. It is also c1e.r that simple separation of smkers and nonsrmkers within the s.me airap.ce msy reduce but csnnot eliminate mnsmDker exposure to environment.1 tobscco amke. The report also reviews sn extensive body of evidence which establishes .n incressed risk of respiratory illness and reduced lung function in infants .nd very young children of psrenta who smoke. This effect ia mire pmmunced if both p.rents anote th.n if only one parent amkes. As . physician, I believe that parents should refrsin from smoking emend sm.11 children both as . means of protecting their children's heslth and to set . pod ersmple for the child. Today, only 30 percent of the adult popul.tion in the United St.Ces are srtokers-the lovest level of waking in the country since YDrld Usr II, reflecting thst the great mjority of the populscion h.. never smked or has successfully quit. Accompanying this decline in overall prevalence of cigarette swking h.s been an incre.sed concern for protecting the health snd well being of nonsmokers, as evidenced by the number of lens snd regulstians restricting smking in public places. Today, 40 St.tea .nd the District of Columbia have enacted some form of legislation to restrict smoking in public. Increasingly, these 1~s pertain to protecting nonawkers in m.ny different setting., including the workplace. Based on the evidence presented in this report, the choice to srmke should mt interfere with the mnslmker's choice for an environment free of tobacco woke. Sincerely, W fl,a. Otis R. Bowen, M.D. secretary FOREWORD The data reviewed in 17 previous U.S. Public Health Service reports on the health consequences of smoking have conclusively established cigarette smoking as the largest single preventable cause of premature death and disability in the United States. The question whether tobacco smoke is harmful to smokers was answered more than 20 years ago. As a result, many scientists began to question whether the low levels of exposure to environmental tobacco smoke (ETS) received by nonsmokers could also be harmful. The current Report, The Health Consequences of Involuntary Smoking, examines the evidence that even the lower exposure to smoke received by the nonsmoker carries with it a health risk. Use of the term "involuntary smoking" denotes that for many nonsmokers, exposure to ETS is the result of an unavoidable consequence of being in proximity to smokers. It is the first Report in the health consequences of smoking series to establish a health risk due to tobacco smoke exposure for individuals other than the smoker, and represents the work of more than 60 distinguished physicians and scientists, both in this country and abroad. After careful examin ation of the available evidence, the following overall conclusions can be reached: 1. Involuntary smoking is a cause of disease, including lung cancer, in healthy nonsmokers. 2. The children of parents who smoke, compared with the children of nonsmoking parents, have an increased frequency of respiratory infections, increased respiratory symptoms, and slightly smaller rates of increase in lung function as the lung matures. 3. Simple separation of smokers and nonsmokers within the same air space may reduce, but does not eliminate, exposure of nonsmokers to environmental tobacco smoke. Exposure to environmental tobacco smoke occurs at home, at the worksite, in public, and in other places where smoking is permitted. vii The quality of the indoor environment must be a concern of all who control and occupy that environment. Protection of individuals from exposure to environmental tobacco smoke is therefore a responsibili- ty shared by all: As parents and adults we must protect the health of our children by not exposing them to environmental tobacco smoke. As employers and employees we must ensure that the act of smoking does not expose the nonsmoker to tobacco smoke. For smokers, it is their responsibility to assure that their behavior does not jeopardize the health of others. For nonsmokers, it is their responsibility to provide a supportr ive environment for smokers who are attempting to stop. Actions taken by individuals, employers, and employee organixa- tions reflect the growing concern for protecting nonsmokers. The number of laws and regulations enacted at the national, State, and local level governing smoking in public has increased substantially over the past 10 years, and surveys conducted by numerous organizations show strong public support for these actions among both smokers and nonsmokers. As a Nation, we have made substantial progress in addressing the enormous toll inflicted by active smoking. Efforts to improve and protect individual health must be not only continued but strength- ened. On the basis of the evidence presented in this Report, it is clear that actions to protect nonsmokers from ETS exposure not only are warranted but are essential to protect public health. Robert E. Windom, M.D. Assistant Secretary for Health . . . vlll PREFACE This, the 1986 Report of the Surgeon General, is the U.S. Public Health Service's 18th in the health consequences of smoking series and the 5th issued during my tenure as Surgeon General. Previous Reports have documented the tremendous health burden to society from smoking, particularly cigarette smoking. The evi- dence establishing cigarette smoking as the single largest preventa- ble cause of premature death and disability in the United States is overwhelming-totaling more than 50,000 studies from dozens of cultures. Smoking is now known to be causally related to a variety of cancers in addition to lung cancer; it is a cause of cardiovascular disease, particularly coronary heart disease, and is the major cause of chronic obstructive lung disease. It is estimated that smoking is responsible for well over 800,000 deaths annually in the United States, representing approximately 15 percent of all mortality. Thirty years ago, however, the scientific evidence linking smoking with early death and disability was more limited. By 1964, the year the Advisory Committee to the Surgeon General issued the first report on smoking and health, a substantial body of evidence had accumulated upon which a judgment could be made that smoking was a cause of disease in active smokers. Subsequent reports over the last 20 years have expanded our understanding and knowledge about smoking behavior, the toxicity and carcinogenicity of tobacco smoke, and the specific disease risks resulting from exposure to this agent. This Report is the first issued since 1964 that identifies a chronic disease risk resulting from exposure to tobacco smoke for individuals other than smokers. It is now clear that disease risk due to the inhalation of tobacco smoke is not limited to the individual who is smoking, but can extend to those who inhale tobacco smoke emitted into the air. This Report represents a detailed review of the health effects resulting from nonsmoker exposure to environmental tobacco smoke (ETS). ETS is the combination of smoke emitted from a burning tobacco product between puffs (sidestream smoke) and the smoke exhaled by the smoker. The 1986 Report, The Health Consequences of Involuntary Smoking, is a critical review of all the available scientific evidence pertaining to the health effects of ETS exposure on nonsmokers. The term "involuntary smoking" is used to ix note that such exposures often occur as an unavoidable consequence of being in close proximity to smokers. Lung Cancer and Environmental Tobacco Smoke The appropriate framework for an examination of the lung cancer risk from involuntary smoking is that of a lowdose exposure to a known human carcinogen. Over 30 years of research have conclu- sively established cigarette smoke as a carcinogen. This Report presents evidence that the chemical composition of side&earn smoke is qualitatively similar to the mainstream smoke inhaled by the active smoker, and that both mainstream and sidestream smoke act as carcinogens in bioassay systems. Data related to environmen- tal levels of tobacco smoke constituents and from measures of nicotine absorption in nonsmokers suggest that nonsmokers are exposed to levels of environmental tobacco smoke that would be expected to generate a lung cancer risk, epidemiological studies of populations exposed to ETS have documented an increased risk for lung cancer in those nonsmokers with increased exposure. It is rare to have such detailed exposure data or human epidemic logic studies on disease occurrence when attempting to evaluate the risk of low-dose exposure to an agent with established toxicity at higher levels of exposure. The relative abundance of data reviewed in this Report, their cohesiveness, and their biologic plausibility allow a judgment that involuntary smoking can cause lung cancer in nonsmokers. Although the number of lung cancers due to involun- tary smoking is smaller than that due to active smoking, it still represents a number sufficiently large to generate substantial public health concern. It is certain that a substantial proportion of the lung cancers that occur in nonsmokers are due to EXS exposure; however, more complete data on the dose and variability of smoke exposure in the nonsmoking U.S. population will be needed before a quantitative estimate of the number of such cancers can be made. Children and Infants This Report also documents a relationship between parental smoking and the respiratory health of infants and children (under 2 years of age). Infants of parents who smoke have an increased risk of hospitalization for bronchitis and pneumonia when compared with infants of nonsmoking parents. There is a relationship between parental smoking and an increased frequency of respiratory symp tams in children. A slower rate of growth in lung function has been observed in children of smoking parents. In many studies, if both X parents smoke, a stronger relationship exists than if only one parent smokes. What future respiratory burden these findings may represent for these children later in life is not known. As a former pediatric surgeon, I strongly urge parents to refrain from smoking in the presence of children as a means of protecting not only their children's current health status but also their own. Diseases Other Than Lung Cancer Several studies have provided data on the relationship between ETS and cancers other than lung cancer and on ETS exposure and cardiovascular disease. However, further research in these areas will be required to determine whether an association exists between ETS exposure and an increased risk of developing these diseases. Policies Restricting Smoking in Public Places The growth in our understanding of the disease risk associated with involuntary smoking has been accompanied by a change in the social acceptability of smoking and by a growing body of legislation, regulation, and voluntary action that addresses where smoking may occur in public. Forty States and the District of Columbia now have some form of legislation controlling or restricting smoking in various public settings. Some States limit smoking to only a few designated areas; however, States are increasingly developing and implement- ing comprehensive legislation that restricts smoking in many public settings, including the workplace. Nine States have restrictions that cover smoking not only by public employees but also by employees in the private sector. No systematic evaluation of the effects these measures may have on smoking behavior has been conducted, but there is little doubt that strong public sentiment exists for implementing such restric- tions. A number of national surveys conducted by voluntary health organizations, government agencies, and even the tobacco industry have documented that an overwhelming majority of both smokers and nonsmokers support restricting smoking in public. Public Health Policy and Involuntary Smoking The 1986 Surgeon General's Report on the Health Consequences of Involuntary Smoking clearly documents that nonsmokers are placed at increased risk for developing disease as the result of exposure to environmental tobacco smoke. Critics often express that more research is required, that certain studies are flawed, or that we should delay action until more conclusive proof is produced, As both a physician and a public health xi official, it is my judgment that the time for delay is past; measures to protect the public health are required now. The scientific case against involuntary smoking as a health risk is more than sufficient to justify appropriate remedial action, and the goal of any remedial action must be to protect the nonsmoker from environmental tobacco smoke. The data contained in this Report on the rapid diffusion of tobacco smoke throughout an enclosed environment suggest that separation of smokers and nonsmokers in the same room or in different rooms that share the same ventilation system may reduce KTS exposure but will not eliminate exposure. The responsibility to protect the safety of the indoor environment is shared by all who occupy or control that environment. Changes in smoking policies regarding the workplace and other environments necessitated by the data presented in this Report should not be designed to punish the smoker. Successful implementa- tion of protection for the nonsmoker requires the support and cooperation of smokers, nonsmokers, management, and employees and should be developed through a cooperative effort of all groups affected. In addition, changes are often more effective when support and assistance is provided for the smoker who wants to quit. Cigarette smoking is an addictive behavior, and the individual smoker must decide whether or not to continue that behavior; however, it is evident from the data presented in this volume that the choice to smoke cannot interfere with the nonsmokers' right to breathe air free of tobacco smoke. The right of smokers to smoke ends where their behavior affects the health and wellbeing of others; furthermore, it is the smokers' responsibility to ensure that they do not expose nonsmokers to the potential harmful effects of tobacco smoke. C. Everett Koop, M.D. Surgeon General xii ACKNOWLEDGMENTS This Report was prepared by the Department of Health and Human Services under the general editorship of the Gffice on Smoking and Health, Donald R. Shopland, Acting Director. Manag- ing Editor was William R. Lynn, Acting Technical Information Officer, office on Smoking and Health. Senior scientific editor was David M. Burns, M.D., Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of California Medical Center, San Diego, San Diego, California. Consulting scientific editors were Ellen R. Grits, Ph.D., Director, Division of Cancer Control, Jonsson Comprehensive Cancer Center, University of California, Los Angeles, Los Angeles, California, John H. Holbrook, M.D., Associate Professor of Internal Medicine, Department of Internal Medicine, University Hospital, Salt Lake City, Utah, and Jonathan M. Same& M.D., Professor of Medicine, Department of Medicine, The University of New Mexico School of Medicine, Albuquerque, New Mexico. The following individuals prepared draft chapters or portions of the Report. Neal Benowitz, M.D., San Francisco General Medical Center, San Francisco, California A. Sonia Buist, M.D., Professor of Medicine, Department of Physiolo gy, Gregon Health Sciences University, Portland, Oregon Charles Hiller, M.D., Pulmonary Division, University Hospital, Little Rock, Arkansas Dietrich Hoffmann, Ph.D., Associate Director, Naylor Dana Institute for Disease Prevention, American Health Foundation, Valhalla, New York Ilse Hoffmann, Research Coordinator, Naylor Dana Institute for Disease Prevention, American Health Foundation, Valhalla, New York John R. Hoidal, M.D., Director of Pulmonary Medicine, University of Tennessee Center for Health Sciences, Memphis, Tennessee John McCarthy, M.P.H., Harvard School of Public Health, Boston, Massachusetts . . . xlll Nancy A. Rigotti, M.D., Institute for the Study of Smoking Behavior and Policy, John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts Jonathan M. &met, M.D., Professor of Medicine, Department of Medicine, The University of New Mexico School of Medicine, Albuquerque, New Mexico John Spengler, Ph.D., Harvard School of Public Health, Boston, Massachusetts Annetta Weber, Ph.D., Federal Institute of Technology, Zurich, Switzerland Scott T. Weiss, M.D., M.S., Associate Professor of Medicine, Chan- ning Laboratories, Harvard Medical School, Boston, Massachu- setts Anna H. Wu, Ph.D., Department of Preventive Medicine, School of Medicine, University of Southern California, Los Angeles, Califor- nia The editors acknowledge with gratitude the following distin- guished scientists, physicians, and others who lent their support in the development of this Report by coordinating manuscript prepara- tion, contributing critical reviews of the manuscript, or assisting in other ways. Elvin E. Adams, M.D., M.P.H., Director, Health and Temperance Department, General Conference of Seventh-Day Adventists, Washington, D.C. Stephen M. Ayres, M.D., Dean, School of Medicine, Medical College of Virginia, Richmond, Virginia David V. Bates, M.D., Professor of Medicine and Physiology, Department of Medicine, Acute Care Hospital, University of British Columbia, Vancouver; British Columbia William J. Blot, Ph.D., Chief, Biostatistics Branch, Epidemiology and Biostatistics Program, Division of Etiology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland. Benjamin Burrows, M.D., Professor of Internal Medicine, and Director, Division of Respiratory Sciences,. The University of Arizona College of Medicine, Tucson, Arizona D. M. DeMarini, Ph.D., Genetic Toxicology Division, U.S. Environ- mental Protection Agency, Research Triangle Park, North Caro- lina Vincent T. DeVita, Jr., M.D., Director, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Louis Diamond, Ph.D., College of Pharmacy, University of Kentucky, Lexington, Kentucky Richard Doll, Cancer Epidemiology and Clinical Trials Unit, Imperi- al Cancer Research Fund, The Radcliffe Infirmary, University of Oxford, Oxford, England, United Kingdom XiV Manning Feinleib, M.D., Dr.P.H., Director, National Center for Health Statistics, Office of the Assistant Secretary for Health, Hyattsville, Maryland Edwin B. Fisher, Jr., Ph.D., Associate Professor, Department of Psychology, Washington University, St. Louis, Missouri William H. Foege, M.D., Executive Director, Task Force for Child Survival, Carter Presidential Center, Atlanta, Georgia Joseph F. Fraumeni, Jr., M.D., Associate Director for Epidemiology and Biostatistics, Division of Cancer Etiology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland Lawrence Garfinkel, M.A., Vice President for Epidemiology and Statistics, and Director of Cancer Prevention, American Cancer Society, New York, New York R.A. Griesemer, D.V.M., Ph.D., Director, Biology Division, Oak Ridge National Laboratory, Oak Ridge, Tennessee Michael R. Guerin, Ph.D., Organic Chemistry Section, Analytical Chemistry, Oak Ridge National Laboratory, Oak Ridge, Tennessee Jeffery E. Harris, M.D., Ph.D., Associate Professor, Department of Economics, Massachusetts Institute of Technology, Cambridge, Massachusetts Millicent Higgins, M.D., Associate Director, Epidemiology and Biometry Program, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Takeshi Hirayama, M.D., Director, Institute of Preventive Oncology, Shinjuku-ku, Tokyo, Japan Dwight Janerich, D.D.S., M.P.H., Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut Martin Jarvis, M.P.H., Senior Clinical Psychologist, Addiction Research Unit, Institute of Psychiatry, London, England, United Kingdom Brian P. Leaderer, Ph.D., M.P.H., Associate Fellow, John B. Pierce Foundation Laboratory, Associate Professor, Department of Epide- miology and Public Health, Yale University School of Medicine, New Haven, Connecticut Charles L. LeMaistre, M.D., President, University of Texas Systems Cancer Center, Houston, Texas Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland Donald Ian Macdonald, M.D., Administrator, Alcohol, Drug Abuse, and Mental Health Administration, Rockville, Maryland James S. Marks, M.D., M.P.H., Assistant Director for Science, Center for Health Promotion and Education, Centers for Disease Control, Atlanta, Georgia James 0. Mason, M.D., Dr.P.H., Director, Centers for Disease Control, Atlanta, Georgia xv J. Michael McGinnis, M.D., Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion), Office of the Assistant Secretary for Health, Washington, D.C. A. J. McMichael, M.D., M.B.B.S., Ph.D., Chairman and Senior Principal Research Scientist, CSIRO Division of Human Nutrition, Adelaide, South Australia D. J. Moschandreas, Ph.D., Research Director, ITT Research Insti- tute, Chicago, Illinois David Muir, M.D., Director, Occupational Health Program, Health Sciences Center, McMaster University, Hamilton, Ontario, Cana- da C. Tracy Orleans, Ph.D., Research Associate, Health Services RX+ search Center, University of North Carolina, Chapel Hill, North Carolina Richard Pete, M.A., MSc., I.C.R.F., Regius Assessor of Medicine, The Radcliffe Infirmary, University of Oxford, Oxford, England, Unit- ed Kingdom Otto Raabe, M.D., Laboratory for Energy Related Health Research, University of California, Davis, Davis, California James L. Repace, Chief of Technical Services, Indoor Air Quality Program, U.S. Environmental Protection Agency, Washington, D.C. M.A.H. Russell, F.R.C.P., Addiction Research Unit, Institute of Psychiatry, University of London, London, England, United King- dom Roy J. Shephard, M.D., Ph.D., Director, School of Physical and Health Education, University of Toronto, Toronto, Canada Frank E. Speixer, M.D., Charming Laboratories, Harvard Medical School, Boston, Massachusetts Jesse L. Steinfeld, M.D., President, Medical College of Georgia, Augusta, Georgia David N. Sundwall, M.D., Administrator, Health Resources and Services Administration, Rockville, Maryland Gregory W. Traynor, Staff Scientist, Lawrence Berkeley Laboratory, Berkeley, California Dimitrios Trichopoulos, Director, Department of Hygiene and Epide- miology, School of Medicine, University of Athens, Athens, Greece Kenneth E. Warner, Ph.D., Professor, and Chairman, Department of Public Health Policy and Administration, School of Public Health, The University of Michigan, Ann Arbor, Michigan Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York James B. Wyngaarden, M.D., Director, National Institutes of Health, Bethesda, Maryland Frank E. Young, M.D., Commissioner, Food and Drug Administra- tion, Rockville, Maryland xvi The editors also acknowledge the contributions of the following staff members and others who assisted in the preparation of this Report. Erica W. Adams, Chief Copy Editor and Assistant Production Manager, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Maryland Richard H. Amacher, Director, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Maryland Margaret L. Anglin, Secretary, Gffice on Smoking and Health, Rockville, Maryland John L. Bagrosky, Associate Director for Program Operations, Office on Smoking and Health, Rockville, Maryland Charles A. Brown, Programmer, Automation and Technical Services Department, Sterling Software, Inc., Rockville, Maryland Clarice D. Brown, Statistician, Office on Smoking and Health, Rockville, Maryland Richard C. Brubaker, Information Specialist, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Mary- land Catherine E. Burckhardt, Secretary, Office on Smoking and Health, Rockville, Maryland Joanna B. Crichton, Copy Editor, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Maryland Stephanie D. DeVoe, Programmer, Automation and Technical Services Department, Sterling Software, Inc., Rockville, Maryland Danny A. Goodman, Information Specialist, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Mary land Patricia E. Healy, Technical Information Specialist, Office on Smoking and Health, Rockville, Maryland Terri L. Henry, Clerk-Typist, Office on Smoking and Health, Rockville, Maryland Timothy K. Hensley, Technical Publications Writer, Office on Smoking and Health, Rockville, Maryland Shirley K. Hickman, Data Entry Operator, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Mary land Robert S. Hutchings, Associate Director for Information and Pro- gram Development, Office on Smoking and Health, Rockville, Maryland Maureen Illar, Editorial Assistant, Office on Smoking and Health, Rockville, Maryland Julie Kurt, Graphic Artist, Information Center Management De- partment, Sterling Software, Inc., Rockville, Maryland Ruth C. Palmer, Secretary, Office on Smoking and Health, Rockville, Maryland xvii Jerome A. Paulson, M.D., Medical Officer, Office on Smoking and Health, Rockville, Maryland Russell D. Peek, Library Acquisitions Specialist, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Mary- land Margaret E. Pickerel, Public Information and Publications Special- ist, Office on Smoking and Health, Rockville, Maryland Raymond K. Poole, Production Coordinator, Health and Natural Resources Department, Sterling Software, Inc., Rockville, Mary- land Linda R. Spiegelman, Administrative Officer, office on Smoking and Health, Rockville, Maryland Evelyn L. Swarr, Administrative Secretary, Automation and Techni- cal Services Department, Sterling Software, Inc., Rockville, Mary- land Debra C. Tate, Publications Systems Specialist, Publishing Systems Division, Sterling Software, Inc., Riverdale, Maryland Jerry W. Vaughn, Programmer, University of California, San Diego, San Diego, California Mary I. Walz, Computer Systems Analyst, Office on Smoking and Health, Rockville, Maryland Louise G. Wiseman, Technical Information Specialist, Gffice on Smoking and Health, Rockville, Maryland Pamela Zuniga, Secretary, University of California, San Diego, San Diego, California . . . XVlll TABLE OF CONTENTS Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Acknowledgments . . . . . . . . . . . . . . . . . . ..*................................ Xl11 1. Introduction, Overview, and Summary and Conclusions . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Health Effects of Environmental Tobacco Smoke Ex- posure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3. Environmental Tobacco Smoke Chemistry and Expo sures of Nonsmokers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 4. Deposition and Absorption of Tobacco Smoke Constit- uents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 5. Toxicity, Acute Irritant Effects, and Carcinogenicity of Environmental Tobacco Smoke . . . . . . . . . . . . . . . . . . . . . . .225 6. Policies Restricting Smoking in Public Places and the Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 xix