Testimony of Gregory N. Connolly, D.M.D., M.P.H. Director,
Massachusetts Tobacco Control Program
Massachusetts Department of Public Health
Boston, Massachusetts
for the Senate Committee on Environment and Public Works
April 1, 1998
on State Public Health Measures to Curb Involuntary Exposure to Environmental Tobacco Smoke

Description of the Problem Second˙2Dhand smoke is the third leading cause of preventable death in the United States of America. Second˙2Dhand smoke results in an estimated 53,000 premature deaths each year. 37,000 from heart disease, 3,700 from lung cancer and 12,000 from other forms of cancer. Only active smoking (420,000 deaths per year) and alcohol (100,000 deaths per year) result in more deaths. The health effects of second˙2Dhand smoke has been reviewed extensively in scientific literature. There are more than 3,000 scientific articles on environmental tobacco smoke. These articles have been summarized in a series of reports done by the Surgeon General, the National Research Council, the Environmental Protection Agency, and most recently by the California Environmental Protection Agency. Just last week new evidence showed that ETS damages the cardiovascular system of exposed non˙2Dsmokers.

Each year in the United States second˙2Dhand smoke causes the following:

_ 53,000 deaths among adults from heart disease, lung cancer, cervical cancer and nasal sinus cancers.

_ 8,000˙2D26,000 new cases of asthma among children.

_ 150,000˙2D300,000 cases of lower respiratory track infections in infants.

_ 7,500˙2D15,000 hospitalizations for lower respiratory track infections in infants.

_ 140˙2D210 infant deaths from lower respiratory track infections.

_ 200,000˙2D 1,000,000 asthma attacks through exacerbation of asthma symptoms among children.

_ 250,000˙2D2.2 million middle ear infections in infants and children.

_ 1,900˙2D2,700 deaths from Sudden Infant Death Syndrome (SIDS).

_ 9,700˙2D19,000 cases of low birthweight due to second˙2Dhand smoke during pregnancy.

Environmental Tobacco Smoke and the Proposed National Settlement

The proposed tobacco settlement provides a minimum standard governing smoking in public places and workplaces by permitting smoking only in separately ventilated areas. It also authorizes OSHA to promulgate regulations and report these standards. However, the settlement exempts restaurants (except fast food restaurants), bars, private clubs, hotel rooms, casinos, bingo parlors, tobacco merchants and prisons. The latter are public areas that have some of the highest levels of second˙2Dhand smoke exposure of any public place and pose significant risks to exposed workers.

Drs. Koop˙2DKessler, in reporting on the settlement, have made a series of recommendations to strengthen the settlement's provisions for involuntary exposure to environmental tobacco smoke. The report calls for total prohibition of smoking in all worksites and all places of public assembly. It also calls for state and local measures prohibiting smoking in all worksites including public awareness campaigns related to the health effects of ETS exposure. The report calls for a complete risk assessment of cardiovascular effects associated with environmental tobacco smoke and the development of economic incentives for business to encourage smoke˙2Dfree worksites. Finally, the report calls for adequate funding of a public education program about the dangers on ETS.

The Massachusetts Approach to Curbing ETS

In 1992, the Massachusetts Division of the American Cancer Society placed a ballot question on the state's ballot to raise the cigarette tax 25_, and allocate a portion of those funds for a comprehensive tobacco control campaign. The ballot question passed 56%˙2D44%, and in the fall of 1993, the state Department of Public Health established the Massachusetts Tobacco Control Program (MTCP).

The MTCP was designed to curtail tobacco death and disease associated with smoking by preventing young people from taking up tobacco use, helping adult smokers to quit, and protecting non˙2Dsmokers from the adverse health effects of environmental tobacco smoke. The state has spent over $125 million since 1993 to curb smoking in the state, and this year's budget is $31 million.

Massachusetts has accomplished much in curbing involuntary exposure to environmental tobacco smoke through the adoption of policies at the local level that prohibit smoking in public places and through an aggressive counter˙2Dadvertising campaign that alerts both smokers and nonsmokers to the dangers of second˙2Dhand smoke. Our campaign has been highly successful, and mirrors much of what the Koop˙2DKessler Commission advocates. Any national settlement could easily adopt the measures we have put in place in Massachusetts to address this problem.

The campaign has three major components, a media campaign ($13 mullions, local policy and prevention initiatives, and cessation services. I will focus on what Massachusetts has done on ETS.

How Massachusetts is Protecting Non˙2DSmokers From Environmental Tobacco Smoke The effort to reduce this risk has taken two parallel paths. First, MTCP˙2Dfunded programs, especially local Boards of Health, have worked to establish institutional or governmental policies to prohibit smoking in areas where non˙2Dsmokers might be affected. Second, MTCP has informed the public about the dangers of ETS through the statewide media campaign as well as public information activities sponsored by local programs, resulting in voluntary adoption of smoking restrictions at home and in public places.

Smoking bans for municipal buildings have been widely adopted. Very few cities and towns banned smoking in municipal buildings before Question 1, and in 1992 fewer than 600,000 Massachusetts residents were protected by such bans. Between 1992 and 1997, however, 101 cities and towns enacted such provisions. The most recent data indicate that such restrictions are in effect in cities and towns whose combined population exceeds 2.9 million˙2Dnearly live times the 1992 figure. Smoking was banned in all schools, and all state government worksites by legislation passed in 1997. Voluntary bans have been adopted in all major sport stadiums, including Fenway Park and Foxboro Stadium.

Mass Media

Our program commits $13 to paid mass media of which one quarter is directed to the damages of ETS. The messages are hard hitting and have greatly increased the awareness of the dangers of ETS and supp ort pass age of local policies.

Helping Employers Control ETS in the Workplace MTCP˙2Dfunded programs have helped employers establish policies restricting smoking in the workplace. Local Boards of Health and the Tobacco Free Worksite Initiative both carry out such activities. Since the programs began in 1994, they have:

_ Initiated contact or responded to requests from over 4,500 worksites; and Provided technical assistance or information to nearly 1,800 of those locations.

499 of those worksites are known to have implemented new tobacco control policies, affecting over 70,000 employees. A survey of Massachusetts' 3,000 largest employers found that 78% have complete smoking bans and 20% require designated smoking areas. Only 2% of these employers have no policy restricting smoking in the worksite.

Massachusetts workers are now significantly less exposed to environmental tobacco smoke than before MTCP began. The percentage of workers in sites that ban indoor smoking climbed from 53% to 65% between 1993 and 1997 surveys. Average ETS exposure at work has fallen from 4.5 to 2.2 hours per week.

Restricting Smoking in Restaurants

Massachusetts residents have strongly and consistently favored policies restricting smoking on restaurants. A 1993 survey found that only 2% preferred a policy of unrestricted smoking in restaurants, while 47% supported complete bans. Provisions restricting smoking in restaurants were relatively rare before Question 1 and nearly always required simply that a portion of the space in the restaurant be designated as non˙2Dsmoking. Since the MTCP local programs began operations, restaurant smoking restrictions have spread widely and the population protected by restrictions on smoking in restaurants has more than doubled. During the same period, moreover, the population protected by complete bans in restaurants has grown from less than 60,000 to nearly 1 million persons.

Smoking bans have not harmed restaurant business. Over 100 Massachusetts cities and towns have enacted some restriction on smoking in restaurants. Some restaurant owners have opposed restrictions, arguing that their business would be adversely affected. Recent analyses of the Massachusetts towns adopting restrictions indicate no adverse effects. If anything, smoking restrictions are associated with gains in restaurant revenues and employment.

After towns adopted highly restrictive restaurant smoking policies, average restaurant receipts were between 5.5 and 8.6 percent higher than if they had not adopted the restrictions. Highly restrictive policies˙2D either a complete ban or a requirement for separate rooms for non˙2Dsmokerswere in force in 29 Massachusetts towns between 1992 and 1995. An econometric analysis using data on meal taxes found that restaurant revenues in these towns exceeded their predicted levels for the periods after adopting the restrictions, where predictions were based on patterns in 22 cities and towns without such restrictions.

A separate analysis suggests that the number of restaurant jobs increased, on average, in towns adopting smoking restrictions. In towns with any kind of smoking restriction, the total number of restaurant employees in 1992˙2D1995 was 9.9 percent higher than would be expected, based on the patterns in towns without restrictions. In towns with highly restrictive policies, the estimated effect was 5.9%, which is within the margin of estimation error.

The analytical results are consistent with research elsewhere, and also with Massachusetts residents' statements about their use of restaurants. Survey respondents say that they would be more likely, rather than less likely, to frequent restaurant, clubs and bars with smoking bans. Moreover, although 37% report that they have avoided going somewhere because they would be "exposed to too much second˙2Dhand smoke," only 9% have avoided going somewhere "because smoking was forbidden."

The Impact of Restrictions on Environmental Tobacco Smoke

Cigarette consumption has dropped by 31% since 1992. Data from the Tobacco Institute show that cigarette purchases in Massachusetts in 1992 totaled 1 i7 packs per person aged 18 or older. By the first half of 1997, purchases had dropped by 31% to 81 packs per capita. The steepest declines occurred in the two years following new excise taxes (1993 and 1997).

Those who do smoke are smoking fewer cigarettes. Part of the decline in cigarette consumption has occurred because Massachusetts smokers are smoking less. The 1993 Massachusetts Tobacco Survey (MTS) found that adult smokers smoked an average of 20 cigarettes per day. That number fell to 16 cigarettes per day in 1996˙2D1997, the most recent two˙2Dyear period of the Massachusetts Adult Tobacco Survey (MATS).

Restrictions on Second Hand Smoke Have Contributed to an Overdecline in Tobacco Use Adult smoking rates are declining. The annual surveys of Massachusetts adults suggests a slow but steady decline in the proportion who smoke. The 1993 survey estimated that 22.6% of Massachusetts adults˙2Dabout one million persons˙2Dwere smokers. The 1997 estimate of 20.6% suggests that the number of adult smokers has fallen by about 9%. This implies a reduction of 90,000 in the number of smokers.

Environmental Tobacco Smoke and National Tobacco Legislation

The current settlement provides little protection to the non˙2Dsmoker from the adverse health effects of environmental tobacco smoke. There are a number of measures that can be included in any national settlement that would do so.

1) Cover the Costs of Second Hand Smoke ;

Environmental tobacco smoke costs the American public money and health each year. These costs are not reflected in the settlement cost and they should be.

2) Include Effective Warnings

Second, the settlement proposes five new warning labels on packages of cigarettes and in cigarette advertisements. None address the effects of second˙2Dhand smoke. Three additional warnings are needed to do so.

WARNING: ENVIRONMENTAL TOBACCO SMOKE CAN KILL. WARNING: ENVIRONMENTAL SMOKE CAUSES RESPIRATORY DISEASE AMONG YOUNG CHILDREN. WARNING: ENVIRONMENTAL TOBACCO SMOKE CAN CAUSE LUNG CANCER AND HEART DISEASE AMONG HEALTHY NON˙2DSMOKERS.

3) Expand ETS Restrictions

The current settlement excludes restaurants, bars, bingo parlors, and other places of hospitality. There is no reason to do so. The current settlement should prohibit smoking in restaurants with a possible phase in ban of smoking within other areas.

4) No Immunity From ETS Lawsuits

The current settlement provides broad immunity from litigation brought because of the adverse health effects of second˙2Dhand smoke. There may be some basis for providing limited immunity for persons whose smoking has caused them disease. However, for exposed non˙2Dsmokers there is no assumption of the risk, and the tobacco industry should not be given protection. These people should not be denied their opportunity to litigate against the tobacco industry. They simply did not assume the risk, and they should not have to pay.

5) Media Campaign

The current settlement allocates over half a billion dollars for a paid national advertising campaign with a focus on youth by Reglorifying and discouraging smoking. It is extremely important that this be expanded to include the adverse health effects of secondhand smoke.